2014 Hcsa Reimbursement Request Form With Instructions printable pdf download

2014 Hcsa Reimbursement Request Form With Instructions

HEALTH CARE SPENDING ACCOUNT

REIMBURSEMENT REQUEST FORM

PLAN YEAR _________

SECTION A

ENROLLEE NAME

STREET ADDRESS

NYS EMPLID

DAYTIME PHONE

AREA CODE

NUMBER

EXT.

CITY

STATE

ZIP CODE

SECTION B

SUMMARY OF HEALTH CARE SPENDING ACCOUNT EXPENSES

DATES SERVICE PROVIDED

NAME OF PERSON

RELATIONSHIP

FROM

AMOUNT TO BE

NAME AND ADDRESS OF PROVIDER OF SERVICES

RECEIVING SERVICES

TO ENROLLEE

MO/DAY/YR

REIMBURSED

(ex.: hospital, doctor, dentist, pharmacy, medical supply store)

TOTAL AMOUNT $______________

I understand, agree and certify to the following:

• I will use my HCSAccount only to pay for IRS-qualified expenses, permitted under the HCSAccount plan, that are provided to me, my spouse and my IRS-eligible dependents, on the date(s) indicated

above as being incurred within my period of coverage during the Plan Year.

• I will request reimbursement only after the health care services have been provided.

• I have not and will not seek reimbursement through any other source, and will exhaust all other sources of reimbursement before seeking reimbursement from my HCSAccount.

• I will collect and maintain sufficient documentation to validate my reimbursed HCSAccount expenses.

• I will not claim any reimbursed HCSAccount expense for any federal income tax deduction or credit.

• I specifically release New York State and FBWW from any liability resulting from either my participation in the HCSAccount or any misrepresentation I make regarding my requests for reimbursement.

• I have read and understand the information contained on the front and back of this form.

ENROLLEE’S SIGNATURE: __________________________________________

DATE: __________________

NEW YORK STATE FLEX SPENDING ACCOUNT

FOR OFFICE

DATE

AUTHORIZATION #

INITIAL

REV.05/14

USE ONLY

A STATE EMPLOYEE BENEFIT THAT PUTS MONEY IN YOUR POCKET