Get State Of Florida Claim Reimbursement Form - State Of Florida Benefits

FSAHC-01 Health Care Flexible Spending Account Claim Reimbursement Form How To Prepare Your Claim Form Step 1 Complete all employee information. This form will be processed electronically. Print clearly and only in the spaces provided* Step 2 Complete expense information* If the expense was incurred for an eligible dependent indicate type of relationship in the box on the dependent name line. Use C for child S for spouse or O for other. Step 3 Sign and date the claim form and attach proof of expense. Bills statements or Explanation of Benefits EOBS from medical plan s are required proof of expense s. Canceled checks are not sufficient evidence as proof of expense. IMPORTANT DO NOT combine multiple expenses on a single line. List each expense separately. Whether submitting single or multiple claims via fax always send the claim form followed by its supporting documentation or receipts. Retain a copy for your records. DO NOT in -4055 Employee Information Please check this box if any of your information has changed PLEASE PRINT Name Employer Name Email Address Address By providing your email address you will receive electronic notifications City State Daytime Phone Zip Social Security Number Instructions Please use blue or black ink and print like this Expense Information Start Date of Service MONTH DAY YEAR 0 1 2 3 4 5 6 7 8 9 NOTE Please report only one expense per block. Combining multiple expenses to one block may result in a delayed reimbursement. Amount DOLLARS CENTS NAME OF PROVIDER TYPE OF SERVICE DENTAL HEALTH RELATIONSHIP TO EMPLOYEE VISION PRESCRIPTION DEPENDENT D. O. B. DEPENDENT NAME To Submit Your Claim Fax to 678 762-5900 or 866 392-4090 Do Not Attach Fax Cover Sheet Or Mail to ADP Claims Processing P. O. Box 1853 Alpharetta GA 30023-1853 Questions and Information Visit www. flexdirect. adp*com Total Expenses Certification I certify that the expenses listed above qualify for reimbursement and have been incurred by me or by eligible members of my family. These expenses have not been reimbursed by my health care plan or any other health care plan such as my spouse s. Additionally these expenses are not being claimed as tax deductions under Section 213 of the IRS code. Print clearly and only in the spaces provided* Step 2 Complete expense information* If the expense was incurred for an eligible dependent indicate type of relationship in the box on the dependent name line. Use C for child S for spouse or O for other. Step 3 Sign and date the claim form and attach proof of expense. Use C for child S for spouse or O for other. Step 3 Sign and date the claim form and attach proof of expense. Bills statements or Explanation of Benefits EOBS from medical plan s are required proof of expense s. Bills statements or Explanation of Benefits EOBS from medical plan s are required proof of expense s. Canceled checks are not sufficient evidence as proof of expense. IMPORTANT DO NOT combine multiple expenses on a single line. Canceled checks are not sufficient evidence as proof of expense. IMPORTANT DO NOT combine multiple expenses on a single line. List each expense separately. Whether submitting single or multiple claims via fax always send the claim form followed by its supporting documentation or receipts.