Enrollee Information

Flexible Benefits - Claim Form

First Name *

Middle Initial

Last Name *

Last 4 of Social Security Number *

Employer *

Email Address *

Expenses

FLEX REIMBURSEMENT PROCEDURES:

The IRS substantiation rules for medical claims reimbursements are very specific. It is based on medical validity, dates of incurred services (not payment dates) and proof that the claim was not elsewhere reimbursed. You need to submit ALL documentation to support this. Please note: Credit Card / Bank Statements are not sufficient receipts and will not be accepted outside of a normal and usual copay of ($25 and $50). Explanation of Benefits, Statement of Services, and Prescription summaries are accepted forms of documentation.

Proper documentation includes a Flex Reimbursement Voucher AND documentation that provides the following information:

Doctors, Specialists, and Hospital Visits need the following:

Patient's Name (who received services?)
Doctor's Name (who performed services?)
Date of Service (date the service was performed; “payment date” & “balance forward” are not eligible)
Service Rendered (what did the doctor do?)
Insurance Reimbursement (what portion is insurance reimbursing? This can be found on an Explanation of Benefits (EOB) from your Insurance Provider if it is not on your doctor's bill. If you decided not to submit for insurance reimbursement, you must send a letter indicating and certifying.)

Prescriptions:

Name of Patient (person drug is for)
Name of Doctor (who prescribed the drug)
Date Filled (date the pharmacy filled the script)
Name of Drug (e.g., Allegra, Vioxx, Concerta)
Insurance Reimbursement (usually says "Insurance Pays $**. ** - You Pay $**. **)

*VITAMINS, SUPPLEMENTS, AND HERBAL MEDICINES ARE NOT REIMBURSABLE WITHOUT APPROVED LMN*

*OVER-THE-COUNTER MEDICAL ITEMS ARE REIMBURSABLE WITHOUT A PRESCRIPTION*

DEPENDENT CARE REIMBURSEMENT:

1. To initiate a Dependent Care Reimbursement, first complete a Dependent Care Registration Statement for all childcare providers that are being claimed for pre-tax reimbursement.

2. Fill out Part III of the Flex Reimbursement Voucher and attach eligible documentation stating the Dependent Care provider, the Dates of Service(s) and the amount charged for care.
3. Submitted receipts will be reimbursed up to the current available balance of the dependent care account.

*Overnight Camps and Sport Training/Lesson are NOT eligible expenses*

*The Dependent Care Registration Statement needs to be completed PRIOR to a Dependent Day Care reimbursement claim being approved and reimbursed*

Recipient of Service *

Date of Service * +

Amount Requested *

Type of Expense *

Diagnosis

Service or Medication Name *

Attach Receipt

Add Another Expense

Recipient of Service *

Date of Service * +

Amount Requested *

Type of Expense *

Diagnosis

Service or Medication Name *

Attach Receipt

Add Another Expense

Recipient of Service *

Date of Service * +

Amount Requested *

Type of Expense *

Diagnosis

Service or Medication Name *

Attach Receipt

Add Another Expense

Recipient of Service *

Date of Service * +

Amount Requested *

Type of Expense *

Diagnosis

Service or Medication Name *

Attach Receipt

*AUTHORIZATION: To the best of my knowledge and belief, my statements in this Reimbursement Voucher are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year and for the eligible plan participants. I certify that these expenses have not been previously reimbursed by this or any other benefit plan and WILL NOT BE CLAIMED AS AN INCOME TAX DEDUCTION.*

Actual receipts must be submitted. If receipts are not attached to this online claim form, copies of receipts must be submitted by mail, fax, or email.

Agree with Authorization? *

Yes

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Questions?? > > Don't hesitate to call us at

(585) 385-6010 or (800) 836-8100

Flexbene
PO Box 587

Pittsford, NY 14534

Fax: (585) 248-2488

info@flexbene.com

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