Usethisformtorequestreimbursementforyourhealthcareexpensesonly.Toviewadetailedlistofeligiblemedicalexpenses,visitFSAFEDS Eligible Expenses Juke Box at www.FSAFEDS.com.Remember,youshouldfirstsubmithealthcareexpensesunderyourFEHBorotherhealthcareplanyoumayhavebeforeyourequestreimbursementfromyourHealthCareFlexibleSpendingAccount.Usethisformonlytorequestreimbursementfor:•Allowableexpensescovered,butnotfullyreimbursed,byanybenefitplans.Attachacopyoftheplan’sExplanationofBenefitsStatement(EOB)
oritemizedreceiptfromyourprovider.•Allowableexpensesnotcoveredbyanybenefitplans.Attachbillsorreceiptswhichindicatethenameandaddressoftheproviderofserviceand
descriptionofserviceprovided.
HOW TO REQUEST REIMBURSEMENT FROM YOUR HEALTH CARE ACCOUNT
Step 1: Fill out the form Pleasetypeorprintincapitalletters,withyourletterscenteredintheboxesprovidedandfillinallovals
asshown:
For Section 1: Completeallareasof“EmployeeInformation.”YoumayuseyourUserIDinsteadofyourSSNinpart1oftheclaimform.Youwillreceiveanemailconfirmingreceiptofyourclaim.
For Sections 2 & 5: Complete a separate line for each individual expense. Do not lump expenses together. •Completeallsectionsoftheform.Signanddatethebottomoftheform. •Pleaseusepage3foradditionalexpensesifyouexceedthenumberoflinesprovidedonpage2.Step 2: Attach supporting documentation In addition to completing the form, you must submit the documentation described under either
A or B below: A. Explanation of Benefits Form (EOB): Thisistheformyoureceiveeachtimeyouorahealthcare
providersubmitmedical,dentalorvisionclaimsforpaymenttoyourhealth,dentalorvisioncareplan.TheEOBwillshowtheamountofexpensespaidbytheplanandtheamountyoumustpay.Forexpensesthatarepartiallycoveredbyyour(oryourdependent’s)medical,dentalorvisionplans,youmustattachtheEOB.Pleaserefertothelistofcodesbelow.
B. All Other Expenses:Forexpensesnotcoveredatallbyyour(oryourdependent’s)medical,dentalorvisionplans,yourclaimmustincludeacceptableevidenceofyourexpenses.Acancelledcheckisnotconsideredacceptableevidence.Acceptableevidenceincludesreceiptswhichcontainthefollowinginformation:
•Typeofserviceorproductprovided •Dateexpensewasincurred •Personororganizationprovidingtheserviceandproduct •AmountofexpenseIfyourreceiptdoesnotclearlyshowthenameoftheproductorserviceprovided,youwillneedtosubmitcopiesoftheUniversalProductCode(UPC)and/orcopiesofthefrontofthebox/containerforover-the-counter(OTC)productsandservices.Step 3: Read the Certification and then sign and date the form where indicatedStep 4: Submit your form • By Fax:Faxtheformandsupportingdocumentationto1-866-643-2245(toll-free).Ifyouaresendingfrom
outsidetheUnitedStates,pleasefaxto1-502-267-2233. • By Mail:Placetheformandthesupportingdocumentationintoanenvelope,applythecorrectpostage,
andmailtoFSAFEDSProgram,POBox36880,Louisville,KY40232. •Keepacopyofyourcompletedformandreceiptsforyourrecords.PleaserememberthatFSAFEDShasaminimumreimbursementthresholdof$25.00.Ifyourclaimdoesnottotal$25.00,itwillbeprocessedandyouwillreceiveareimbursementstatement,butyourpaymentwillbependeduntilyousubmitanotherclaimandreachthe$25.00aggregateamount,oruntiltheendofthequarter,whichevercomesfirst.IfyoudonotselectaPlanYear,wewilldefaulttotheappropriateyearaccordingtothedateofservice,uptotheavailablebalance.
NOYESA B C D 1 2 3 4
Type of Supporting Documentation:•Itemizedreceiptfromyourmedical,dentalorvisionproviderorpharmacy•Itemizedreceiptforover-the-countermedicines–mustshowthenameoftheproduct•ExplanationofBenefits(EOB)fromyour insurancecompanyorhealthcareprovider•Documentationmustshow:
• Dateexpensewasincurred • Typeofserviceornameofproduct • Amount(yourportionofpayment) • Personororganizationprovidingthe
serviceandproduct
Please Do NOT :•Useredink•Useaphotocopyoftheform•Highlightreceiptsoranypartoftheform•Stapleyourcopiedreceiptstotheform•Writeoutsidetheboxesprovided•Iffaxing,faxthesameformmorethanonce•Mailthesameformthatyouhavefaxed•Includethisinstructionsheetwithyourfax
COVERAGECODES–YoumustincludeacodeinSections2and5oftheform.
Medical codes 102=over-the-countermedicines 103=prescriptionsorprescriptionco-pays 104=generalmedical
Dental codes202=generaldental(cleanings,x-rays,crowns,implants,dentures)
Vision codes303=generalvision(exams,glasses,contactlenses)Other codes
999=other
Questions? Need a list of eligible expenses? Go to www.FSAFEDS.com or contact an FSAFEDS Benefits Counselor at 1-877-FSAFEDS.
Page 1 - HEALTH CARE CLAIM FORM
Page 2 - HEALTH CARE CLAIM FORM
FAMILY MEMBER
VHVFVXVUSE AN ORIGINAL FORM (NOT A PHOTOCOPY)
.$
.$
EXPENSE 1 DATES OF SERVICE (MMDDYY)FROM
TO (MMDDYY)
AMOUNT REQUESTED (DOLLARS . CENTS)COVERAGE CODE (SEE PAGE 1)
EOB ATTACHED?
YES
YES
NO
NO
EXPENSE 2 DATES OF SERVICE (MMDDYY)FROM
TO (MMDDYY)
AMOUNT REQUESTED (DOLLARS . CENTS)
EOB ATTACHED?
YES
YES
NO
NO
COVERED BY INSURANCE?
COVERED BY INSURANCE?
SECTION 3: CERTIFICATION Please read thoroughly before signing.
SECTION 2: YOUR HEALTH CARE EXPENSES
SECTION 1: EMPLOYEE INFORMATION
HEALTH CARE CLAIM FORMUse only CAPITAL LETTERS
FAX TO: 1-866-643-2245 TOLL-FREE or 1-502-267-2233For additional expenses, please use next page.
VHVFVXV
FOR SHPS USE
EMPLOYEE LAST NAME EMPLOYEE FIRST NAME
DAYTIME PHONE # (AREA CODE FIRST, NO DASHES)EMPLOYEE EMAIL
PROGRAM NAME
FSAFEDS
EMPLOYEE USER ID (NO DASHES)
FAMILY MEMBER
COVERAGE CODE (SEE PAGE 1)
I affirm that:• I HAVE NOT ALREADY BEEN PAID FOR THESE EXPENSES FROM MY FSA AND I HAVE NOT REQUESTED and wILL NOT RECEIVE REIMBURSEMENT FOR
THESE EXPENSES FROM ANY OTHER PLAN INCLUDING FEDVIP (Federal Employees Dental and Vision Insurance Program) and FEHB (Federal Employees Health Benefits Program); AND
• I have submitted the above information in good faith and it is correct to the best of my knowledge. I understand that:• Reimbursement is not a guarantee that this payment is tax-free.• The service(s) for which I am requesting reimbursement must be incurred during my period of coverage, which begins the next January 1 if I enrolled
during the Open Season, or the day after my enrollment is accepted by FSAFEDS, whichever is later, and ends no later than March 15 of the following year, unless my coverage ends sooner due to a Qualifying Life Event.
• I have until April 30 to submit my claim for reimbursement of eligible expenses incurred during my period of coverage. If I do not submit claims for reimbursement by that date, I will forfeit any funds remaining in my account(s) in accordance with IRS rules.
• Health care expenses reimbursed through my general purpose HCFSA or LEX HCFSA cannot be used as a deduction on my personal income tax return. I authorize release of payment through my Flexible Spending Account. I authorize FSAFEDS, or its representatives, to obtain necessary information from all physicians, hospitals, medical service providers, pharmacists, employers, and all other agencies or organizations (including other insurers) to consider the claim for reimbursement under my Flexible Spending Account.
* Your signature is required in order to process your claim for reimbursement.
Employee Signature* Date
MAIL: FSAFEDSProgramPOBox36880Louisville,KY40232
PHONE: 1-877-FSAFEDS(1-877-372-3337)TTY:1-800-952-0450
2007 PLAN YEAR
2008 PLAN YEAR
.$
EXPENSE 3 DATESOFSERVICE(MMDDYY)FROM
TO(MMDDYY)
AMOUNTREQUESTED(DOLLARS . CENTS)COVERAGECODE(SEEPAGE1)
EOBATTACHED?
YES
YES
NO
NO
COVEREDBYINSURANCE?
FAMILYMEMBER
USEANORIGINALFORM(NOTAPHOTOCOPY)
Page 3 - HEALTH CARE CLAIM FORM
EMPLOYEEUSERID(NODASHES)
FBZSHXP
FBZSHXP
EMPLOYEELASTNAME
SECTION 5: YOUR ADDITIONAL HEALTH CARE EXPENSES
SECTION 4: EMPLOYEE INFORMATION (ABBREVIATED)
USE THIS PAGE FOR ADDITIONAL HEALTH CARE EXPENSES.
.$
EXPENSE 4 DATESOFSERVICE(MMDDYY)FROM
TO(MMDDYY)
AMOUNTREQUESTED(DOLLARS . CENTS)COVERAGECODE(SEEPAGE1)
EOBATTACHED?
YES
YES
NO
NO
COVEREDBYINSURANCE?
FAMILYMEMBER
.$
EXPENSE 5 DATESOFSERVICE(MMDDYY)FROM
TO(MMDDYY)
AMOUNTREQUESTED(DOLLARS . CENTS)COVERAGECODE(SEEPAGE1)
EOBATTACHED?
YES
YES
NO
NO
COVEREDBYINSURANCE?
FAMILYMEMBER
.$
EXPENSE 6 DATESOFSERVICE(MMDDYY)FROM
TO(MMDDYY)
AMOUNTREQUESTED(DOLLARS . CENTS)COVERAGECODE(SEEPAGE1)
EOBATTACHED?
YES
YES
NO
NO
COVEREDBYINSURANCE?
FAMILYMEMBER
.$
EXPENSE 7 DATESOFSERVICE(MMDDYY)FROM
TO(MMDDYY)
AMOUNTREQUESTED(DOLLARS . CENTS)COVERAGECODE(SEEPAGE1)
EOBATTACHED?
YES
YES
NO
NO
COVEREDBYINSURANCE?
FAMILYMEMBER
EMPLOYEE FIRST NAME
