Fillable Flexible Spending Account (FSA) Claim Reimbursement Request Form (University of Akron)

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Flexible Spending Account (FSA) Claim Reimbursement Request Form (University of Akron)

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Flexible Spending Account (FSA)
Claim Reimbursement Request Form
COMPANY INFORMATION (PLEASE PRINT)
Company Name
Division
(if applicable)
PARTICIPANT INFORMATION (PLEASE PRINT)
Last Name Primary Phone ( ) -
First Name
Secondary
Phone
( ) -
SSN /
(
or Alternate Employee ID)
Date of Birth
(mm/dd/yyyy)
/ /
Email Address
(For Account Notifications)
Street Address
(Check if New Address )
City State
Zip
If your claim includes expenses incurred by a spouse or eligible dependents, please provide the following information:
NAME RELATIONSHIP TO EMPLOYEE DATE OF BIRTH

/ /

/ /

/ /
REIMBURSEMENT REQUEST (PLEASE PRINT)
Please indicate your qualifying expenses below. DO NOT include expenses reimbursed by any other source.
HE
A
LTHC
A
RE
–
FLEXIBLE SPENDING
A
CCOUNT (FS
A
)
Attach copies of bills, receipts, Explanation of Benefits (EOBs) or other claim documentation. Documentation must include dates of service, description
of service and the expense amount. Cancelled checks and/or credit card statements/receipts are NOT sufficient proof of your claim.
DATE RANGE OF SERVICES
From / / through / /
TOTAL Healthcare
Reimbursement Request
$
(REQUIRED)
DESCRIPTION (Please list a brief description below of services – ie: Rx, copay, contact solution, etc…)
IMPORTANT: If this is a limited healthcare Flexible Spending Account - Submit claims only for dental and/or vision expenses
DEPENDENT D
A
YC
A
RE
–
FLEXIBLE SPENDING
A
CCOUNT (FS
A
)
The following information is REQUIRED: Business name; dates of service and the expense amount; either a receipt/bill OR your provider’s signature
below. NOTE: Cancelled checks are acceptable for daycare expenses only; credit card statements/receipts are NOT sufficient proof of your claim.
DATE RANGE OF SERVICES
From / / through / /
TOTAL Dependent
Daycare Reimbursement
Request
$
(REQUIRED)
PROVIDER’S TAX ID or SSN PROVIDER’S BUSINESS or NAME


Dependent Daycare Provider’s Signature: Date
/ /
CL
A
IM CERTIFIC
A
TION
I certify these expenses for which reimbursement is requested on my Flexible Spending Account have been incurred by me, my spouse or my eligible
dependent(s) and are not payable by any other benefit plan/program. I will not claim credit for these expenses on my individual income tax return.
Participant Signature (Required) Date
/ /
SEND THIS FORM WITH A COPY OF YOUR RECEIPTS TO CHARD SNYDER
(DO NOT SEND ORGINAL RECEIPTS)
Please submit this form with
y
ou
r
r
e
q
uired Fax: Local 513.459.9947
/
Toll-Free 888.245.8452
Please D
O
NO
T
in
c
l
ude a Fa
x
Cover Pa
g
e
)
documentation to Chard Snyde
r
by one
of the three methods listed to the right.
Mail:
Email:
3510 I
r
win Simpson Rd, Mason, OH 45040
askpenny@chard-snyder.com
FSA Claim Form v5.15
Flexible Spending Account
Claim Reimbursement Instructions
1. Complete all company and employee information on the front page (please print/type). NOTE: Please
include your e-mail address to receive an automatic e-mail notification whenever a claim is entered into our
system and when a reimbursement is approved for you to receive payment
2. Attach supporting documentation. A copy of a receipt or EOB must accompany this request for each claim
submitted for reimbursement. Do not highlight any part of your receipt. Be sure to keep your original receipts,
bills, etc. for your records. All receipts are destroyed daily. Each claim request must include the following
information to be eligible for reimbursement:
Original date of service (not the date of payment)
Description of service performed (refer to list of eligible expenses to identify valid services)
Provider’s name and address (If submitting receipts for dependent daycare expenses)
Amount charged to you (do not include amounts reimbursed by another source)
3. Healthcare – Flexible Spending Account Reimbursement Request: Complete all required information
(ie: Total Reimbursement Request Amount) and attach proof of expense as described above. Cancelled
checks are NOT acceptable as proof of payment. Limited healthcare Flexible Spending Accounts may only
reimburse claims for dental and/or vision expenses
4. Dependent Daycare – Flexible Spending Account Reimbursement Request: Complete all required
information (ie: Total Reimbursement Request Amount) and attach proof of expense as described above.
Note: Cancelled checks are acceptable as proof of payment
5. You MUST sign and date the ‘CLAIM CERTIFICATION’ section on the front of this page
6. Fax, Mail or Email this form and supporting documentation directly to Chard Snyder:
Fax: Local 513.459.9947 / Toll-Free 888.245.8452 (Please DO NOT include a Fax Cover Page)
Mail: 3510 Irwin Simpson Rd, Mason, OH 45040
Email: askpenny@chard-snyder.com
7. If you have questions please contact us:
Call Customer Service: 513.459.9997 | 800.982.7715
Visit our Website: www.chard-snyder.com
Email your questions: askpenny@chard-snyder.com
8. Important Reminders:
All requests are saved as electronic images. To ensure your claim is processed as soon as possible, and
avoid delays:
Do NOT use a fax cover page when faxing
Do NOT highlight any part of your receipts, bills, etc.
Only send copies of receipts, bills, etc. (Keep your originals)
Multiple receipts should be totaled on one claim form
Payments are issued after receipt and processing, subject to claim approval
Claims may not be paid across accounts (healthcare from dependent daycare and vice versa)
Any items for which you are reimbursed cannot be claimed again as deductions or credits on your
individual tax return at the end of the tax year
Dependent daycare claims may only be reimbursed for the amount you have in your account at the
time of your claim. If your claim is for more than the balance in your account, the rest of your claim will
be paid when more money is added
You may only be reimbursed for eligible expenses incurred during the current plan year
Note: Orthodontia expenses are reimbursed as designated by the provider
Payment will be made directly to you. Payments cannot be made to a provider or another person
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Flexible Spending Account (FSA) Claim Reimbursement Request Form (University of Akron)

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Completed 24 July 2020

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