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ysa claim form(npc)11.12.2010 (1)

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 Health Care/Dependent Care Claim Form  P.O. Box 785040 Orlando, FL 32878-5040 Fax: 1-888-211-9900 Name (Last, First MI) Last 4 of SSN (Optional) Employer Name ZIP Code HEALTH CARE CLAIMS Date of Service (MM-DD-CCYY) Provider Type of Service* Patient Requested Amount $ $ $ $ $ Health Care Total $ *Type of Service: Dental Health Care Supplies Hearing Medical Over-the-Counter Medicine Prescription Vision  DEPENDENT CARE CLAIMS Dates of Service (MM-DD-CCYY to MM-DD-CCYY) Service Provider Dependent Requested Amount to $ to $ to $ to $ to $ Dependent Care Total $ EMPLOYEE CERTIFICATION By adding my signature below, I certify that the information I’m providing is correct and the expenses for which I’m requesting reimbursement, or for which I’m validating:  Were incurred for services or supplies received by my eligible dependents or me under the plan;  Were for services or supplies furnished on or after the date my spending account takes effect;  Haven’t been reimbursed in any other way or from any other source and won’t be submitted for future reimbursement; and  Don’t include any amounts that are otherwise payable by plans for which my dependents or I are eligible.  For OTC medicine expenses, I’m submitting a valid prescription and itemized receipt. I understand that health care reimbursements aren’t eligible deductions on my individual tax return. Claim decisions will be made in accordance with the provisions of the plan.  Signature Date

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