Flexible Spending Account Claim Form
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1
2Flexible Spending Account
Claim Form
Today’s Date:
/
/
# of pages:
Plan Year: 20
New Claim
Response to Claim Denial
Employee Name:
Employer Name/Division Name:
Employee Address:
Please check if change of address; you must also change with your HR department.
Social Security Number or
Work Phone: (
)
Home Phone: (
)
Member ID Number:
*
Minimum check reimbursement is $25; minimum reimbursement for direct deposit is .50
Health Flexible Spending Account
Total Amount Requested:
Dependent Care Reimbursement Account
Total Amount Requested:
Dependent Care Provider Signature:
X
Date:
/
/
Note: you MUST include the provider Tax ID Number in the service provider column in the table below. If you use the
account to pay for the cost of a babysitter, you must provide the babysitter’s Social Security Number. If you cannot remit a
copy of your bill/contract, your daycare provider must sign on the line below in lieu of submitting a receipt.
Individual Premium Reimbursement Account
Total Amount Requested:
*For reimbursement from this account please attach proof of the non-employer sponsored policy.
Adoption Assistance Account
Total Amount Requested:
Date of
Employee, Spouse
Amount
Type of Service
Service Provider/ R
x
Service
or Dependent
Requested
(R
co-pay, dental
Number
x,
expense, etc.)
1.
2.
3.
4.
5.
I certify that the above listed expenses have been incurred by me or by my spouse or dependent(s) and that they have not been
reimbursed under any other health plan; furthermore, I will not seek reimbursement of the expenses under any other health plan.
Employee’s Signature:
Date:
/
/
Revised 4/10/2015
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