FAX TO: MAIL TO QUESTIONS:
1-877-879-9038 ASI WEBSITE: WWW.ASIFLEX.COM/DEBITCARD
PAGE # ______ OF _______ PO BOX 6044 MAIL: ASI@ASIFLEX.COM
NO COVER PAGE REQUIRED COLUMBIA, MO 65205-6044 PHONE: 800.659.3035
CARDCLAIM 09272013
DEBIT CARD DOCUMENTATION
If you received a request from ASIFlex to provide documentation of a card transaction, please complete this form in its entirety, provide legible
documentation as instructed, and sign below. Please print clearly.
Your Name (Last, First, MI)
Social Security No. or EID or PIN
Documentation Required by IRS Guidelines - The IRS requires that all card transactions be substantiated. Although some transactions may be
substantiated electronically, many require you to provide supporting documentation. Why? The card company reports only limited information to
ASIFlex such as the card transaction date, merchant name and dollar amount. The IRS requires that you provide a description of the service, the
patient name, and the actual date the service was provided, regardless when you paid. Not all services/supplies are qualified health care expenses
(such as cosmetic treatments, teeth bleaching, non-prescription sunglasses, general health items, warranty contracts, etc.). The IRS requires you to
provide documentation for all dental, vision and hospital expenses; and for copayments that do not match your employer plan’s flat-dollar
copayment amount. If the service/supply is determined to be ineligible, you must repay the ineligible amount to the plan. You can mail a check to ASI
or contact finance@asiflex.com to arrange for the amount to be debited from your bank account. Alternatively, you can submit a manual paper claim
to off-set the ineligible amount.
Complete the information below and provide documentation to substantiate the card transaction(s). Acceptable documentation includes:
• Your insurance payer Explanation of Benefits (EOB) statement
• Itemized statement from your health care provider that includes these five things:
o Health care provider name/address
o Patient Name
o Date the service/supply was provided (not when you were billed, or when you paid)
o Description of the health care service/supply
o Dollar amount charged that matches the card transaction
• Pharmacy receipt, printout or mail-order statement
• Itemized cash register receipt for over-the-counter health care products
Note: Examples of unacceptable documentation include:
cancelled checks
credit card receipts
balance forward/amount due/paid-on-account statements
pre-treatment estimates
statements for future dates of service, pretreatment estimates
Name of Health Care
Provider
Description of Service
(X-ray, Lab, Crown, Eyeglasses, etc.)
I certify that all expenses were incurred by me, an eligible spouse, or an eligible dependent during a period while I was covered under my employer's Plan and that the expenses have not
been reimbursed and reimbursement will not be sought from any other source. I understand that I am fully responsible for the accuracy of all information relating to this documentation,
and that unless an expense is a qualified expense under the Plan, I may be liable for payment of all related taxes including federal, state, or local income tax on amounts paid from the Plan
which relate to such expense. This request will only be processed with this completed and signed Debit Card Documentation form and correct documentation. I understand the card may be
temporarily inactivated until such time that complete and appropriate documentation is provided and/or until such time that I pay any owed amounts back to the Plan.
Employee Signature _____________________________________________ Date_____________________________________
