Fillable Aflac Benefit Services Request for Reimbursement Form Check (City of Bixby)

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Aflac Benefit Services Request for Reimbursement Form Check (City of Bixby)

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The Aflac Benefit Services Request for Reimbursement Form Check (City of Bixby) form is 1 page long and contains:

  • 2 signatures
  • 1 check-box
  • 106 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Bixby

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Medical Care FSA Claim Information
Employee Information
❑ Check here if address change
Aflac Benefit Services Request for Reimbursement Form
Instructions: Please print or type the information below.
1. Sign and date form.
2. The Medical Care Total requested boxmust be completed.
3. Receipts attached must be clear and legible. Please maintain copies of all receipts for your records.
Participant’s Social Security Number (Optional) Employer Name
Last Name First Name Middle Initial Participant's E-Mail Address
Street Address City State ZIP
By submitting this claim form, I request reimbursement from my FSA account as listed below. I agree to the Terms and Conditions outlined in my employer’s
Summary Plan Description. I certify and warrant to Aflac that these are eligible medical expenses that I or my dependents have incurred, are not cosmetic in nature,
and cannot be reimbursed from any other source. I will maintain copies of all documentation for my records.
Participant’s Signature: ____________________________________________________________________________ Date: ______________________________
For Medical Care expenses, an Explanation of Benefits (EOB) from your insurance company or other receipt(s) must be submitted. The EOB and/or
attached bills must contain the following items to be processed and approved:
1. Patient Name 2. Service Provider 3. Description of Service 4. Date(s) service was provided 5. Amount/Copay
List each receipt separately in the space(s) below • Use additional forms if necessary • A total must be indicated in the Total block below.
Use the Provider Certification space below only if no receipt is attached • Do not indicate “see attached” in the spaces below.
FSA Card Date Service Requested
Receipt Patient Name Service Provider Description of Service Was Provided Amount
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Provider Certification
In lieu of receipts or EOB(s) the provider of the service can certify that the above listed medical care expenses have been incurred and only incurred by either the participant or
his/her dependents. Any other expenses must have receipts or a separate completed form. Failure to complete all items will result in an invalid claim request.
Provider Name and Address: ____________________________________________________ City: ____________________ State: ______ ZIP: _____________
Provider Signature: ________________________________________________________________________________ Date: _______________________________
I certify that the Medical Care expenses listed above were incurred by the patient named above.
M0272BURM R-8/10
TOTAL $
$ 0.00
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Helpful Tips for Filing Your Claim
Sample Health FSA Expenses
This list is not all-inclusive; for more detailed information, refer to the Participant Handbook. Unreimbursed medical expenses are reviewed according to the
regulations of Internal Revenue Code Section 125. All claims must be substantiated, and appropriate documentation must be provided.
Some expenses may require additional documentation from your doctor or health care provider.
Insurance Medical Equipment Vision Care
Eligible Eligible Eligible
Deductibles, copayments, and Wheelchairs/ crutches Prescription eyeglasses
coinsurance for medical care plans Blood sugar monitors Contact lenses and cleaning solution
Oxygen equipment Prescription sunglasses
Hearing aids, batteries, or hearing aid repairs
Ineligible Ineligible Ineligible
All premiums/contributions for insurance Equipment replacement insurance and/or Lens replacement insurance/warranties
Long-term care plans warranties Protection plans
Expenses paid totally by your health plan Vacuum cleaners for individuals with dust Coatings/tints not used to treat
allergies a medical condition
Treatments/Therapies Dental/Orthodontic Care Drugs
Eligible Eligible Eligible
Prescribed weight loss programs to treat a medical Routine exams, cleaning, and X-rays Prescription drugs
condition (not including foods) Artificial teeth/dentures to treat a medical condition
Diagnostic services (e.g., X-ray and MRI treatments) Braces and orthodontic services Birth control
Smoking cessation programs Insulin
Fertility treatments
Ineligible Ineligible Ineligible
Illegal treatments Teeth bleaching/whitening Dietary supplements for general health,
Physical treatments for general well-being or relaxation Tooth bonding that is not medically necessary to include vitamins and herbs
(e.g., massage therapy) (e.g., cosmetic veneers) Drugs for cosmetic purposes,
over-the-counter medicines, unless
prescribed by a physician.
Fees/Services Miscellaneous Charges
Eligible Eligible
Physician consultation fees Sales tax associated with an eligible item
Routine office visits Transportation expenses primarily for
Nursing services for care of a specific ailment medical care, to include mileage, bus, taxi,
Legal sterilization parking fees and/or tolls
Ineligible Ineligible
Cosmetic procedures that improve appearance but do not Divorce, even when recommended by a psychiatrist
meaningfully promote the proper function of the body or Diaper service
treat an illness/disease Toiletries or cosmetic items
Payments to domestic help for nonmedical services (e.g., toothbrush, soap, lotion, etc.)
Retainer or concierge fees Maternity clothes
1. Complete, sign and date the FSA Request for Reimbursement Form. Failure to complete all areas will result in claim rejection and a delay in
processing and reimbursement. Do not indicate "See Attached" in any field. Descriptions of service should provide as much detail as possible.
If a provider certification is used, the provider must sign and date each new claim form.
2. Submit documentation that is clear and legible. Do not highlight information; these areas often turn black when scanned. In addition, double
check to make sure all documentation is clearly visible and not overlapped, written through, or cut off if photocopied.
3. Verify that services received are eligible expenses. See below or refer to your Participant Handbook for general guidance.
4. The deadline or run-off period for claims submission is determined by your employer. For more information on the run-off period, refer to your
employer or your Summary Plan Description. To avoid delays, submit your claims at least two weeks prior to the end of your run-off period.
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Aflac Benefit Services Request for Reimbursement Form Check (City of Bixby)

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Completed 10 June 2021

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