Public Employees Health Program, FLEX$ Claims
Jordan School District
560
East
200
South,
Suite
100,
Salt
Lake
City,
Utah
84102-2004
FLEXIBLE REIMBURSEMENT
801-366-7503 TOLL FREE 800-753-7703
PROGRAM {FLEX$)
FAX 801-366-7772 TOLL FREE 800-759-8772
CLAIM FORM
PLAN YEAR FROM SEPTEMBER 1 TO AUGUST
31
EMPLOYEE INFORMATION
EMPLOYEE NAME (last, first, middle initial)
IID#
PLAN YEAR:
HOME ADDRESS
CITY/STATE/ZIP
DAYTIME PHONE
Please
complete
ALL
applicable
spaces.
Enclose
copies
of
ONE
of
the following
documents
for
each item claimed: An Explanation
of
Benefits
(EOB)
from
your
insurance
company,
OR
a
recelpt'statement
detailing
the
services
provided,
date
of
service
and
the
total
out-
of-pocket
expense.
Indicate
the
item
number
to
which
they
pertain.
Include
a
Doctors
note
when
required.
Consult
the
FLEX$
Handbook
for
items
requiring a
Doctor's
note.
(www.pehp.org).
The
first
orthodontia
claim
must
include
a
copy
of
the
written
agreement
between
you
and
the
orthodontist, indicating
the
total
estimated
charges
and
the
period
of
treatment. Please keep a copy
of each claim for your records.
QUALIFIED HEAL TH CARE EXPENSES
ITEM
NO.
OATE OF SERVICE
NAME OF PROVIDER
EXPENSE DESCRIPTION
CLAIM
AMOUNT
1
2
3
4
5
6
7
Claims
must
be
for
services
performed within
the
Plan
Year
TOTAL
1. A
FLEX$
HANDBOOK
WITH
DETAILED
PLAN
RULES
ANO
INFORMATION
IS
AVAILABLE
AT
www.pehp.org.
2.
YOU
HAVE
90
DAYS
FROM
THE
END
OF
THE
PLAN
YEAR
TO
FILE
CLAIMS
FOR
THE
PRIOR
PLAN
YEAR.
3.
IF
YOU
RETIRE
OR
TERMINATE
FROM
EMPLOYMENT,
YOU
HAVE
60
DAYS
TO
FILE
CLAIMS
FOR
EXPENSES
INCURRED
PRIOR
TO
YOUR
TERMINATION
DATE.
QUALIFIED DEPENDENT DAY CARE EXPENSES
ITEM
NO.
DATE OF SERVICE
NAME OF PROVIOER
PROVIDER TAX ID/SSN (Required)
CLAIM
AMOUNT
1
2
3
4
5
Claims
must
be
for
services
performed
within
the
Plan
Year
TOTAL
I,
the undersigned, hereby certify that the expenses for which reimbursement is sought herein are expenses that
I,
the Participant believe
in
good faith are Qualified Health Care Expenses and/or Qualified Dependent Day Care Expenses during the Plan Year for myself, my spouse
and/or
my
legal dependents. I also certify that these expenses have
not
and will not be claimed for reimbursement under any other Flexible
Spending Plan, insurance plan or claimed as a deduction on a tax return.
EMPLOYEE
SIGNATURE
DATE
PEHP
APPROVAL
Unsigned claims
will
not
be
processed.
The
employer and the Pian Administrator reserve the right to verify to their satisfaction all claimed ex.penses prior
to
reimbursement
and
to
refuse any amounts that are not Qualified Health Care Expenses and/or Qualified Dependent Day Care Expenses
..
FCF-JSO
6-05
