Flexible Spending Account Health Care Reimbursement

Flexible Spending Account
Health Care Reimbursement
Mail or fax completed form and documentation to:
0BAetna Inc.
PO Box 4000
Richmond, KY 40476-4000
Fax to: 1-888-238-3539 (1-888-AET-FLEX)
For the hearing impaired, call 1-877-703-5572 TDD/TTY
*** UYou must sign and date this form to avoid claim payment delay.U ***
*** Refer to Instructions on reverse side. ***
1. Employee Information
Employee’s FSA Identification Number
W
Employee’s Last Name First MI
Daytime Telephone Number
( ) -
Street Address City State Zip Code
2. Employer Information
Employer Name
FSA Control Number
3. Expense Information
Patient’s First Name
Relationship to Employee
Self Spouse Dependent
Date of Birth (MM/DD/YYYY)
Date(s) of Service (MM/DD/YYYY)
From / / Thru / / Total Amount Submitted $
Patient’s First Name
Relationship to Employee
Self Spouse Dependent
Date of Birth (MM/DD/YYYY)
Date(s) of Service (MM/DD/YYYY)
From / / Thru / / Total Amount Submitted $
Patient’s First Name
Relationship to Employee
Self Spouse Dependent
Date of Birth (MM/DD/YYYY)
Date(s) of Service (MM/DD/YYYY)
From / / Thru / / Total Amount Submitted $
Patient’s First Name
Relationship to Employee
Self Spouse Dependent
Date of Birth (MM/DD/YYYY)
Date(s) of Service (MM/DD/YYYY)
From / / Thru / / Total Amount Submitted $
4. Orthodontia Expenses – Read Section 4 on the reverse side of this form before completing this section.
Patient’s First Name
Relationship to Employee
Self Spouse Dependent
Date of Birth (MM/DD/YYYY)
Date(s) of Service (MM/DD/YYYY)
From / / Thru / / Total Amount Submitted $
5. Coordination of Benefits (COB)
Are you or any family members for whom you are requesting reimbursement eligible to receive benefits under any medical, dental, prescription or vision plan other
than your primary coverage?
Yes – You must include copies of all EOBs. No
6. Employee Certification
I certify that the expenses for which I am seeking reimbursement from the Flexible Spending Account have been incurred by
me, or by an individual who qualifies as my spouse or my dependent under IRS guidelines. I further certify that these
expenses have not been reimbursed, nor shall reimbursement be sought, from any other health plan coverage, including a
Health Savings Account (HSA). I also certify that I have not, and will not, claim a tax deduction or credit for these expenses
on my federal income tax return, or on my state or local tax returns in violation of state or local law. I agree to submit and
retain sufficient documentation for any expense for which I seek reimbursement.
Any person who knowingly and with intent to defraud files a statement of claim containing any materially false, incomplete or
misleading information is guilty of a crime.
Sign Here ► Employee Signature Date U
GC-11 (9-10) F R-POD
Page 1/2
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Flexible Spending Account Health Care Reimbursement PDF

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