Microsoft word - fsa claim form.doc

FLEXIBLE SPENDING ACCOUNT (FSA)
REQUEST FOR REIMBURSEMENT FORM
Employer ________________________________________________________________________________________________ Employee Name ____________________________________________________ Soc.Sec.No. ___________________________ Last First M.I. Home Address ____________________________________________________________________________________________ Number/Street City State Zip Daytime Telephone Number _______________________________ E-mail Address _____________________________________ Please check only if this is a new address Direct Deposit Authorization – Please complete this section to have your FSA reimbursements direct deposited into your
checking or savings account. This is a faster, more secure method of reimbursement. If you are already set up for direct deposit, there is no need to complete again. You may attach a voided check if you are unsure of your routing and/or account number. HEALTH CARE FSA
(See documentation requirements and guidelines on reverse side of claim form) DEPENDENT CARE FSA
Please attach a receipt or statement from your dependent care provider showing the “from/through” dates of service, or have your provider sign the receipt on the back of this form. Please note: services must actually be rendered prior to requesting reimbursement (see reverse). I certify that I have not previously requested reimbursement for the above expense under this plan or any other plan, and I will not seek reimbursement from any other health plan coverage or any other source. I also certify that the expenses were incurred by me and/or my IRS dependents, and will not be applied toward any federal or state income tax deduction or credit. _____________________________________________________________________________________________________________ Note: To access your balance and claims history, you may register for online access to your account information at www.myrsc.com.
Contact Arcadia for your “employer code” to register. You must sign this form to be reimbursed. Mail or fax to:

Arcadia Benefits Group, Inc. • 445 W. Michigan Ave., Suite 102 • Kalamazoo, MI 49007
Phone: 269-744-3431 • Toll Free: 866-329-4333 • Fax: 269-381-5844 • E-mail: [email protected] Rev. 11/07
INSTRUCTIONS AND DOCUMENTATION REQUIREMENTS FOR FSA REIMBURSEMENT
Please read these instructions before completing the front of this form. Failure to provide the information required by the IRS could
delay your reimbursement. All copies must be legible.
Documentation requirements for Health Care expense reimbursement:
1. For
medical or dental expenses that will be processed under your underlying insurance plans, please submit the expenses to your
insurance carrier first. Then submit a copy of the Explanation of Benefits (EOB) to Arcadia with this form. Proof of payment of the
expense is not required.
2. If you do not have insurance coverage for dental expenses, submit an itemized statement from your dentist showing the patient
name, name and address of the provider, date of service, description of service and amount of charge. Some dental expenses that are not eligible are teeth bleaching and veneers placed for cosmetic reasons. orthodontia expenses, please submit a copy of the Truth in Lending Statement (contract/treatment plan) with your initial
submission itemizing the treatment period, down payment and amount of monthly payments, and the amount covered by insurance, if any. Submit a copy of your monthly payment coupon and/or itemized receipt each time you request reimbursement for ongoing treatment. Note: the plan cannot reimburse for future service or for the portion of treatment occurring in another plan year unless a lump sump is paid for the full cost of the treatment at the beginning of treatment. vision expenses, if you do not have insurance coverage for vision, submit an itemized receipt from your vision provider
showing the date of service, description of charge (exam, Rx glasses, contacts, etc.) and amount of charge. Some vision expenses that are not eligible are warranty charges, protection plans and sun-clips for prescription glasses. To be reimbursed for contact lens solutions and cleaners, you may submit a cash register receipt as long as the receipt shows a description of the item. If not, you must submit a portion of the package with the price along with the cash register receipt to verify the item purchased. Rx and Over-the-Counter (OTC) Drug co-payments, submit a copy of the Rx co-payment receipt showing the patient name,
name of the drug, date the Rx was filled, and co-payment amount. For OTC drug reimbursement, submit a copy of your cash register receipt detailing the name of the OTC drug, date purchased and amount. If the cash register receipt does not specify the name of the OTC drug, submit a tear-off portion of the box or package that includes the name and price, and submit along with the cash register receipt. Some Rx and OTC drugs are not eligible for reimbursement, including drugs taken for cosmetic reasons (i.e., Rogaine or Retin-A) or drugs taken for weight loss (unless there is a specific medical necessity). OTC drugs taken for general good health are also not eligible (e.g., vitamins and supplements). 6. For other expenses, always submit itemized statements. A letter of medical necessity may need to accompany some charges (i.e., massage therapy, tutoring for a learning disability, and cosmetic procedures).
The total annual election for eligible health care expenses (less any previous reimbursements paid) is available from the beginning of
the plan year. For a more complete list of eligible expenses, you may obtain a copy of IRS Publication 502; however, premiums are not
eligible for reimbursement. An eligible health care expense is any item for which you could have claimed a medical expense deduction
on Schedule A of your federal income tax return (with the exception of insurance premiums). Expenses must be incurred by you or your
dependents while participating in the plan.
Documentation requirements for Dependent Care expense reimbursement:
1. Submit a receipt or statement from your day care provider showing the “from/through” dates of service, description of the charge
(i.e., child care or preschool) and the amount of the charge. Proof of payment is not required. You may have your provider sign the receipt at the bottom of this form each time you request reimbursement. 2. Some expenses associated with dependent care are not eligible, including overnight camp, food and transportation costs. If you are submitting charges for a day camp, please make sure the documentation shows that it is a day camp. 3. Your claim cannot be processed until after the services have actually been rendered. For example, if you pay your child care weekly on a Monday for that week, you should submit your claim on Friday after the services have been rendered. If you pay your child care expenses on a monthly basis, you will need to wait until the last day of the month to submit for reimbursement. IMPORTANT: You must provide the IRS with the name, address and Tax I.D. (or Soc. Sec. No.) of the dependent care provider on your federal income tax return. If you are unable to provide this information, the exclusion for the dependent care spending account may be denied by the IRS. Receipt for Child Care Services

For the Time Period: ___________ through ___________
For the Amount of $___________
Paid by: _________________________________________
Received by: _____________________________________
Date: _____________________________

Source: http://www.glenoaks.edu/facultystaff/HumanResources/Documents/FSA%20Claim%20Form.pdf