Rev. 08/2011 Phone: (800) 473-9595
FSA/HRA 200-8 Website: www.BenefitResource.com
FSA/HRA REIMBURSEMENT CLAIM FORM (Please Print Clearly)
PART 1 PART 2 Check here if address has changed and provide new information below.
Employee Name: Street or PO Box:
Member ID: City:
Employer: State: Zip Code:
PART 3
Provider & Service Rendered/Item Purchased
*Pay from
Prior PY?
Date
s
of Service
Amount For Office Use Only
YES
YES
YES
YES
YES
YES
YES
YES
YES
TOTAL º
Submit claim by:
Fax: (585) 427-9320
or
Mail: ATTN: Claims Department
Benefit Resource, Inc.
245 Kenneth Drive
Rochester NY 14623-4277
Signature Required: _____________________________________ Date: _____
Employee Certification: By signing the above, I request reimbursement for Medical and/or
Dependent Care expenses listed above. Enclosed are itemized bills, receipts or EOBs verifying
these expenses. Each expense listed is for a service/item provided to me, my spouse or an
eligible dependent, has not been purchased with a Beniversal® MasterCard® Prepaid Card, and
will not be reimbursed from any other source. Medical expenses were incurred only for an
immediate medical purpose. I understand that these expenses must qualify for reimbursement
under the Internal Revenue Code and cannot be claimed as deductions on my personal income
tax.
*If your plan offers the extended grace period allowed by IRS regulations, you must check Yes if you wish to have this expense reimbursed from the prior plan year.
INSTRUCTIONS FOR SUBMITTING YOUR CLAIM:
1. Part 1 of the claim form must be completed in full.
2. Part 2 of the claim form should only be completed if your address has changed.
3. Part 3 of the claim form must be completed in full.
4. For each item you are claiming in Part 3, you must attach a copy of itemized bills, statements, receipts or insurance company Explanation of Benefits (EOBs). This
documentation from your provider must include the following information (please retain originals for your personal records).
• Name of provider • Your out-of-pocket cost for the service
• Date(s) service was provided • Name of person receiving the service
• Type of service provided (for prescriptions, must include name of drug)
5. IRS regulations require additional documentation for the following:
• Effective 01/01/2011, over-the-counter drugs and medicines require a prescription.
• Dual purpose items require a Certification of Medical Necessity form (can be obtained from the Benefit Resource website).
6. The claim form must be signed and dated after reading the Employee Certification.
7. Submit the completed claim form and all related documentation to: Fax: (585) 427-9320 or ATTN: Claims Department
Benefit Resource, Inc.
245 Kenneth Drive
Rochester NY 14623-4277
C
LAIM SUBMISSION REMINDERS:
• Credit card statements, cancelled checks and balance forward/prior balance statements are not acceptable.
• The service being claimed must be provided to you, your spouse or your eligible dependent within the time frame indicated in your Plan Highlights.
• In general, IRS regulations do not require that you pay for a service before requesting reimbursement. A request for reimbursement must be based on the date when the
service was provided, not the date when a payment was made. (The IRS allows one exception: orthodontia expenses can be based on date of payment, date of service or
payment due date on statements/coupons.)
• Claims must be submitted after a service is provided, but before the end of the run-out period following the end of your plan year.
• Claims must be received by Benefit Resource, Inc. within the time frames specified in the Plan Highlights.
• An expense paid with the Beniversal Card or that has been reimbursed from any other source cannot be submitted for reimbursement.
• Items on a claim form or supporting documentation should never be highlighted since highlighted items can be hard to read.
S
OME EXPENSES THAT ARE NOT ELIGIBLE FOR REIMBURSEMENT FROM A MEDICAL REIMBURSEMENT ACCOUNT INCLUDE:
• Personal care items (e.g. shampoo, soap, electric toothbrush, toothpaste, mouthwash)
• Teeth whitening
• Insurance premiums
S
OME EXPENSES ARE ONLY ELIGIBLE FOR REIMBURSEMENT FROM A MEDICAL REIMBURSEMENT ACCOUNT IF CERTIFIED BY A LICENSED MEDICAL PROVIDER AS
PREVENTING, TREATING, OR MITIGATING A SPECIFIC PHYSICAL DEFECT OR ILLNESS:
• Cosmetic services
• Vitamins
• Non-prescription sunglasses
• Exercise and weight loss programs
Sign Here
