Flexible Spending Account (FSA) Claim Form
Employer Name:
Employee Name:
Last First MI
Last 4 SS#:
Employee Address:
Street City State ZIP
PHONE:
Email Address:
Please check if this is a new address
Explanation of Benefits (EOB) must be provided as proof of expense. Detailed invoice/receipt may be accepted if no EOB is available.
EMPLOYEE'S CERTIFICATION FOR REIMBURSEMENT
I certify that the expenses for reimbursement indicated on this substantiation form were incurred by me (and/or my spouse and/or eligible
dependents), and were not reimbursed by any other plan nor will I seek reimbursement from any other source. To the best of my
knowledge and belief, the expenses are eligible for reimbursement under my Reimbursement Plan. I (or we) will not use the expense
reimbursed through this account as deductions or credits when filing my (our) individual income tax return.
Any person who knowingly and with intent to injure, defraud, or deceive any insurance company, administrator, or plan service provider,
files a statement of claim containing false, incomplete or misleading information may be guilty of a criminal act punishable under law.
Employee Signature: ___________________________________________________________Date: ________ /________ /________
FOR PROCESSING, SEND TO: Querbes & Nelson Benefits Department
MAIL: Querbes & Nelson
P.O. Box 1802
EMAIL: benefits@qnins.com
PHONE: (318)
429-0529
PHONE: (318) 429-0516
SHREVEPORT, LA 71162
MEDICAL FSA EXPENSE CLAIMS
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Date(s) of
Payment
Date(s) of
Service
Patient
Relationship to
Employee
Name of Provider/
Description of
Service
Claim
Amount
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No
$
Yes
No
$
Yes
No
$
Yes
No
$
Yes
No
$
Yes
No
$
Yes
No
$
Centenary College of Louisiana
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