EBPA Confidential Reimbursement FAX Cover Sheet

EBPA Reimbursement Department 1-888-678-3457
The material in this FAX is confidential. Please be sure it is received by the intended recipient as soon as possible.
EBPA Reimbursement FAX Cover Page
To: EBPA Reimbursement Department FAX #: 1-603-773-4415
Participant’s Name:
___________________________
Employer Name:
__________________
DATE:
Number of pages
Including this cover page: ____________
Participant’s Contact Information: Telephone Number or Email Address
___________________________________________________
RECOMMENDED
You may obtain copies of this FAX Cover Sheet at: http://www.ebpabenefits.com/members
Important Claim/Substantiation Submission Information
Please check the box that applies
New Claim Submission
To ensure there are no delays in processing your claim(s), you are required to complete, sign and submit an
"FSA Reimbursement Claim Form" for all new reimbursement claims.
(Found on your FSA webpage at www.ebpabenefits.com under Member Access)
Substantiation / Documentation Submission
Please remember to include a copy of the "Substantiation Letter" or "Denial Letter" when submitting your
response and/or documentation. Please do not submit a new Reimbursement Form.
MESSAGE:
_____________________________________________________________________________________
__________________
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EBPA Confidential Reimbursement FAX Cover Sheet PDF

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