Fillable Form 1: (City of New York)

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Form 1: (City of New York)

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BROWSE CITY OF NEW YORK FORMS

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Health Care Flexible Spending Account (HCFSA) Program
2) EMPLOYEE (PARTICIPANT) INFORMATION (PLEASE TYPE OR PRINT CLEARLY)
last name first name mi. social security number
home
address - number and street check here if this is a new address apt. no.
city state zip code email address:
home or cell (daytime) phone number work phone number agency name (not division)
( ) - ( ) -
3) HCFSA REIMBURSEMENT REQUESTS
Please read “Instructions and Important Information” on the reverse side before completing this form and refer to your enrollment information for
HCFSA rules and regulations. If the service was provided for more than one day, show the beginning date and the ending date of the service. Each
claim must be separated by patient, date/type of service and dollar amount.
1
patient last name patient first name mi.
date(s) of service (mm/dd/yy) types of service reimbursement amount requested
from
______/______/______ to ______/______/______ Medical RX OTC Dental Vision Hearing Aid $
claim period (check only one)
2020 Plan Year (services incurred 1/1/20 - 12/31/20) 2019 Plan Year (services incurred 1/1/19 - 12/31/19) 2019 Grace Period (services incurred 1/1/20 - 3/15/20 using 2019 balance)
provider’s name
provider’s address - number and street apt. no.
city state zip code
2
patient last name patient first name mi.
date(s) of service (mm/dd/yy) types of service reimbursement amount requested
from
______/______/______ to ______/______/______ Medical RX OTC Dental Vision Hearing Aid $
claim period (check only one)
2020 Plan Year (services incurred 1/1/20 - 12/31/20) 2019 Plan Year (services incurred 1/1/19 - 12/31/19) 2019 Grace Period (services incurred 1/1/20 - 3/15/20 using 2019 balance)
provider’s name
provider’s address - number and street apt. no.
city state zip code
3
patient last name patient first name mi.
date(s) of service (mm/dd/yy) types of service reimbursement amount requested
from
______/______/______ to ______/______/______ Medical RX OTC Dental Vision Hearing Aid $
claim period (check only one)
2020 Plan Year (services incurred 1/1/20 - 12/31/20) 2019 Plan Year (services incurred 1/1/19 - 12/31/19) 2019 Grace Period (services incurred 1/1/20 - 3/15/20 using 2019 balance)
provider’s name
provider’s address - number and street apt. no.
city state zip code
TOTAL REIMBURSEMENT AMOUNT REQUESTED (1+2+3) $___________________
4) EMPLOYEE (PARTICIPANT SIGNATURE) - If you are unable to sign the form or import your electronic signature, the form will be accepted by
typing your name in the signature eld.
The above is a true and accurate statement of unreimbursed health care expenses incurred by me and/or my eligible dependent(s) on the date(s) indicated. I
certify that I and/or my eligible dependent(s) have incurred these expenses and have not been previously reimbursed and are not eligible for reimbursement
through any other plan. I understand that expenses reimbursed herein cannot be deducted from my or anyone else’s individual Federal Income Tax return. All


Signature ________________________________________________________________________________________________ Date ______/______/______
Did you remember to:
Complete all sections? Choose the correct claim period?
Sign and date the form? Attach EOB statement(s), bill(s) and appropriate documentation?
20202020_06/20
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
HEALTH CARE FLEXIBLE SPENDING ACCOUNT (HCFSA) PROGRAM
CLAIMS FORM


HCFSA
1) INSTRUCTIONS AND IMPORTANT INFORMATION
 




not be processed.
2. 
-

divided between these two accounts.
3. After the Claims Run-Out Period has ended, any unclaimed year-end balance in your account will not be carried into the next
Plan Year and will be forfeited.
 -
ment can be made prior to services being received.
 
6. -
bursement at the end of the following month.
 


statement.
Each EOB, bill, receipt or claims form must contain the following information:
   
   
 

8. 

9. Denitions
a) Eligible Medical Expense: An expense which has been incurred by the participant for qualifying health care expenses provided for
and which is eligible for reimbursement pursuant to the terms of

b) Qualifying Health Care Expense: 
health care recipient; (ii) not reimbursable by a health insurance carrier and/or Welfare Fund; and (iii) not for the payment of health
insurance premiums
Note: 
not

c) Eligible Health Care Recipients:



Note
 

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Completed 16 August 2020

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