Page 1 of 1 - Welfare-508 (10/2012)
Please fax, mail, or email your claim form and receipts to the following:
Mail: National Benefit Services, LLC, P.O. Box 6980, West Jordan, UT 84084
Fax: Salt Lake Area Fax: (801) 355-0928 ● Toll Free Fax: (800) 478-1528
Email: claims@NBSbenefits.com (PDF, TIFF, or JPG files only)
Flexible Spending Account (FSA)
Claim Form
Instructions For Quick Claim Processing:
• Fully complete & sign this claim form
• Attach copies of supporting EOB, receipts, vouchers, bills, etc.
• All receipts must detail each of the items summarized below
• Please list one expense per line
• Please print in dark blue or black ink when using this form
• Minimum Total Reimbursement = $25
•
Please allow 2 business days for claims to be processed
For Account Balance:
Go to www.NBSbenefits.com
or call (801) 838-7324 or (888) 353-9125
**Notice**
All over-the-counter (OTC) medication claims must be accompanied by a
prescription to be eligible under new federal regulations
1 Personal Information
Employee Name Company Name
No Yes
Street Address, City, State, Zip Address Change?
Phone Number Social Security Number
Dependent Care Expenses
Date of Service
Service Provider Tax ID# or SS#
Dependent’s Name
Age
Amount
MM DD YY
1
2
3
Total Dependent Care Expenses
3 Health Care Expenses
Date of Service Office
Visit
Rx Dental Vision
Non-
Drug
Ortho
dontia
Other Services:
Please Specify
Person Receiving
Service
Amount
MM DD YY
1
2
3
4
5
6
7
8
9
Total Health Care Expenses
4 Employee Signature
I, the undersigned, attest that to the best of my knowledge these statements are complete and true. I authorize the release of any medical information to my spouse. I certify
these expenses are for valid services provided on the dates indicated and will not be reimbursed or claimed under any other Plan or claimed as a tax deduction.
Employee Signature Date
