Please type or print all information
COMPANY NAME:
Social Security Number: (for security purposes please provide at least the last 4 digits of you ss#)
Employee Last Name:
Employee First Name:
Flex debit card used for
this expense
Date of
service
Provider name or name of store Amount
YES NO
YES NO
YES NO
YES NO
YES NO
MEDICAL EXPENSES
• Documentation for each request will need to show date of service, description of service provided and charge for
service as well as the providers name and address.
• Please itemize your expenses to help assure proper processing. If you have more expenses than this form allows please
attach a separate form. If you do not itemize your expenses we will process your claim based on the documentation
received
• Mail claims to: 9246 Portage Industrial Dr, Portage MI 49024; Fax: 800-391-6562 or Email to claims@basiconline.com
• For questions call 800-444-1922 ext 1 or 269-327-1922 ext 1
*CARD*
Flex debit card used for
this expense
Dates of
service
Day care provider name Amount
YES NO
YES NO
YES NO
YES NO
DAY CARE EXPENSES
(dependent care account)
• Please have your day care provider sign this form on the line below or provide a receipt for the services
SIGNATURE OF DAY CARE PROVIDER:
ONLY USE THIS FORM IF YOU
HAVE ONE OF THESE CARDS
- -
Revised 4.11.08
Eastern Michigan University
