Amount Requested
for Reimbursement
Amount Requested
for Reimbursement
Phone (
I certify that I have not previously requested reimbursement for the above expenses under this or any other plan and I am not able to receive additional insurance
benefits or reimbursements from any other source for these expenses. I certify that these expenses are eligible for reimbursement in accordance with the
Flexible Spending Account SPD provided by my employer. I further certify that these expenses are for eligible dependents as defined under Internal Revenue
Code Section 152.
Please complete one section for each included receipt and total at the bottom. Use additional forms as needed.
Name Of Provider Patient Name
Name Of Provider Patient Name
Name Of Provider Patient Name
Name Of Provider Patient Name
First
REIMBURSEMENT REQUEST DETAIL
PLEASE PRINT CLEARLY. USE ALL CAPITAL LETTERS.
If this is a new address check here
-
-
)
-
E-Mail
Last
FSADirect REQUEST FOR MEDICAL REIMBURSEMENT
Group:
REIMBURSEMENT AUTHORIZATION
ACCOUNT HOLDER GENERAL INFORMATION
Partic. ID#
Name
Address
City State Zip
Claim Submission Deadline:
You have until the above day after
the end of the plan year to submit
claims for the previous plan year.
Participant Signature (Void if not signed) Date Signed
Plan ID:
Date Of Service (not payment date)
IMPORTANT INSTRUCTIONS:
• You must attach an itemized bill or explanation of benefits (EOB) form for healthcare
expenses. Do not attach checks or credit card slips as you may be required to provide additional
documentation.
• Expenses that CAN NOT be reimbursed include cosmetic expenses, insurance premiums,
and general wellness expenses.
• Fax the claim to 1-800-726-9982 or 704-335-0818 in the Charlotte area.
Or mail to:
Flores & Associates • P.O. Box 31397 • Charlotte, NC 28231-1397
Total Requested
For This Page
Service Code (See key below)
Amount Requested
for Reimbursement
SERVICE CODE KEY
01 - Medical 03 - Vision 05 - Mileage 07 - Other
02 - Dental 04 - Prescription 06 - Orthodontia 08 Over The Counter
Date Of Service (not payment date) Service Code (See key below)
Date Of Service (not payment date) Service Code (See key below)
Amount Requested
for Reimbursement
Date Of Service (not payment date) Service Code (See key below)
Customer Service: 1-800-532-3327
PLEASE DO NOT USE STAPLES
