Get Medicare Reimbursement Form

Alliedbenefit. com E-mail Flexclaims alliedbenefit. com FLEX ADMINISTRATION FLEXIBLE SPENDING REIMBURSEMENT REQUEST FORM Section I. Allied Benefit Systems Inc* 208 S* LaSalle St* Suite 1300 Chicago IL 60604 Tel 312-906-8080 Option 3 Toll-Free 800-288-2078 Outside IL Fax 312-416-2870 www. Employer/Employee Information Employer Name Group Number Employer Location if applicable Employee SSN Flex Plan Year Address City State 20 Zip Day Time Phone Employee E-mail Address Section II. Reimbursement Request Please attach all receipts that apply to requested reimbursements. For dependant care please attach receipts or have a Tax ID and signature of the Dependant Care Provider. Type of Health Flexible Spending Account FSA Expense s Date of Service Amount of Expense s Medical Dental / Vision RX OTC / Other Total Reimbursement Requested Dependent Care Assistance DCA Expense s Name of the Dependent Expense s Were Incurred For Dependent s Age Providers Tax ID Number Providers Signature or Attach Receipt Section III. Participant Certification I certify that the expenses for which I am requesting reimbursement for meet the following conditions The above expenses were incurred for services or supplies for me and/or my eligible dependents listed above which either reside with me in a parent child relationship or are legally dependent on me for their support. The above services and supplies were furnished to me or my dependents on or after my effective date with the Plan* I have not been reimbursed for the above expenses nor have any of my dependents been reimbursed for these expenses. I understand that any amounts not used for qualified expenses by the end of the Plan Year or Grace Period will be forfeited to my Employer. I have not and will not itemize and deduct nor claim credit for these expenses on my income tax returns. Reimbursement will be made in accordance of the provisions of the Plan* Employee Signature Date FLEX REIMBURSEMENT REQUEST. Employer/Employee Information Employer Name Group Number Employer Location if applicable Employee SSN Flex Plan Year Address City State 20 Zip Day Time Phone Employee E-mail Address Section II. Reimbursement Request Please attach all receipts that apply to requested reimbursements. For dependant care please attach receipts or have a Tax ID and signature of the Dependant Care Provider. Reimbursement Request Please attach all receipts that apply to requested reimbursements. For dependant care please attach receipts or have a Tax ID and signature of the Dependant Care Provider. Type of Health Flexible Spending Account FSA Expense s Date of Service Amount of Expense s Medical Dental / Vision RX OTC / Other Total Reimbursement Requested Dependent Care Assistance DCA Expense s Name of the Dependent Expense s Were Incurred For Dependent s Age Providers Tax ID Number Providers Signature or Attach Receipt Section III. Type of Health Flexible Spending Account FSA Expense s Date of Service Amount of Expense s Medical Dental / Vision RX OTC / Other Total Reimbursement Requested Dependent Care Assistance DCA Expense s Name of the Dependent Expense s Were Incurred For Dependent s Age Providers Tax ID Number Providers Signature or Attach Receipt Section III. Participant Certification I certify that the expenses for which I am requesting reimbursement for meet the following conditions The above expenses were incurred for services or supplies for me and/or my eligible dependents listed above which either reside with me in a parent child relationship or are legally dependent on me for their support.