Reimbursement Form
Last Name: First Name: Last Four Digits of SSN#:
Street: City: State:Zip:
Employer: Email: Phone:
Health Care Reimbursement Worksheet
Start Date
End Date
Recipient
Merchant Name
TOTAL
Day Care Reimbursement Worksheet
Start Date
End Date
Provider Tax ID or SSN#: TOTAL
Preferred method of reimbursement (check one) CHECK DIRECT DEPOSIT
Please include bank information for direct deposit:
We only need bank information once. account # routing #
I request reimbursement from my account. I certify that the information provided is true and correct, that these expenses are not and will not be covered by any
insurance program or other reimbursement program, and that I have not nor will not claim these expenses as income tax deductions on my income tax return, and
that the expenses submitted qualify as required. I also understand that the Internal Revenue Service (IRS) may require proof that these are eligible expenses, and
that I am responsible for providing such proof.
CheckBoxforElectronicSignatureDATE: / /
Please send this form along with your documentation to: FlexSave of America, Inc. ● 22811 Greater Mack ● Suite
201 ● St. Clair Shores ● MI. ● 48080 or fax to
Please leave blank if we already have your banking information
Signature of Child Care Provider
:___________________________________________ or send billing/invoice statement.
Don't forget you can submit claims for reimbursement through the participant portal at www.mywealthcareonline.com/flexsave
you agree to the terms above by checking this box
