Submit Claims To:
Custom Design Benefits, Inc.
5589 Cheviot Road
Cincinnati, Ohio 45247
Ph: (800) 598-2929
Fax: (513) 598-2901
FlexClaims@CustomDesignBenefits.com
Employer:
Employee: Employee or SSN #:
Check if new address Address:
City: State: Zip Date of Birth:
E-mail: Phone:
TO ENSURE WE CAN PROCESS YOUR CLAIM:
ATTACH A COPY OF THE EXPLANATION OF BENEFITS (EOB) -- This must be provided for each patient. If you
do not have the EOB, we may be able to accept other documentation. Examples of what we can accept:
Provider bills. Must show service dates, description of services, patient name, insurance payments, amount applied to
deductible or out-of-pocket, amount owed.
RX claims . RX bag receipt or pharmacy print-out showing name of drug, patient name, date filled and amount paid.
Please note that cash register receipts and credit card statements do NOT have enough information for submitting claims.
CLAIMS RECEIVED LESS THAN 24 HOURS PRIOR TO THE PLAN’S SCHEDULED CHECK ISSUING DATE WILL BE PROCESSED ON THE NEXT
SCHEDULED DATE.
HRA REIMBURSEMENTS REQUESTED
Date of Service Name of Service Provider Service Description Patient Name Claim Amount
Total Amount of HRA Claim
$
TOTO A
Read Carefully: The undersigned participant in the Plans certifies that all services for which reimbursement or payment is claimed by submission
of this form were provided during a period while the undersigned was covered under the Company’s Plans with respect to such expenses and that
the health expenses have not been reimbursed or are not reimbursable under any other health plan coverage. The undersigned fully understands
that he or she alone is fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim which is provided by the
undersigned, and that unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned
may be liable for payment of all related taxes including federal, state, or city income tax on amounts paid from the Plans which relate to such
expense.
________________________________________________________ __________________________________
Employee’s Signature Date
View your Account Online at www.CustomDesignBenefits.com (click on MyFlexOnline Login)
Health Reimbursement Account
