Doctor’s Statement for Healthcare Expense
The Internal Revenue Service requires a doctor’s statement be provided for certain healthcare expenses in order
to be reimbursed from your healthcare Flexible Spending Account (FSA) or Health Reimbursement Arrangement
(HRA). The doctor’s statement must indicate the specific medical disorder, the specific treatment needed, and
how this treatment will alleviate the medical condition.
The following form will assist you and your healthcare provider in providing the information we need in order to
process your reimbursement request or Benny
®
transaction. Your provider can also write a letter on his or her
letterhead, as long as the letter includes all the information on this form.
For fast and accurate processing of your reimbursement request or Benny
®
, please make sure to include this
doctor’s statement form or your provider’s letter along with an itemized receipt or other documentation.
Please note: If your treatment extends beyond the time period listed below, you will need to submit a new doctor’s statement.
Employee Name
Employee SSN
Email address
Phone Number
Patient Name
Diagnosis
Recommended Treatment
How will the recommended
treatment alleviate the
diagnosis or symptoms?
Length of treatment
Provider Name
Provider Address
Provider Telephone #
Provider Signature
Date
Benefit Resources, Inc.
4775 E. 91
st
Street, Suite 100
Tulsa, OK 74133
Phone (918)-481-6161 Toll free (800) 339-7493
Fax (918) 481-6181 Toll free (866) 364-7052
Email: claims@britulsa.com
