Request for
Reimbursement
from FSA or HRA
PO Box 2797 Portland, OR 97208-2797
Phone (541) 485-7488 (800) 422-7038
FAX (866) 446-6090
Submit claims electronically through MyFlex at:
PacificSource.com/PSA
EMPLOYEE INFORMATION
Employer 11-digit Member ID
_______________ __
Employee Last Name First Name Middle Initial
Employee Mailing Address (Street) (Apt. #) (City) (State) (ZIP)
Home Phone Work Phone Email Address
Please check if address above is new
HEALTH-RELATED EXPENSES (for amounts not charged to your Benny™ MasterCard
®
)
Per IRS guidelines, please attach appropriate documentation (explained on the reverse of this form). One form may be
used for multiple expenses. Do not send original documentation. Check the appropriate boxes below:
FSA/HRA = Health-related expenses such as deductibles, copays, prescriptions, dental, vision, etc.
SPA = Supplemental insurance premiums for dental, vision, fire and ambulance policies, etc.
Type of Expense (please check FSA/HRA or SPA):
FSA/HRA SPA Service Date Amount Brief Description
$
$
$
$
$
Total Reimbursement (add amounts): $
DEPENDENT CARE EXPENSES
Expenses include childcare and/or pre-school up to age 13, adult daycare for tax dependents.
Child’s Age Service Period Amount Provider’s Signature
$
$
$
Total Reimbursement (add amounts): $
*Signature of provider is necessary only if sufficient documentation is not available (see reverse for more information.)
AUTHORIZATION
To the best of my knowledge, my statements in this Request for Reimbursement are complete and true. I am claiming reimbursement
only for eligible expenses incurred for eligible plan participants during the applicable Plan Year. I certify that these expenses have not
been, nor are they expected to be, reimbursed under this or any other benefit plan, and will not be claimed as an income tax deduction.
I have read and understand the information provided on the reverse of this form. I authorize my flexible spending account or health
reimbursement arrangement to be reduced by the amount requested above.
Employee Signature (required) Date
Total number of pages:
Request for Reimbursement from FSA or HRA_0714
PacificSource.com/PSA
REIMBURSEMENT REQUEST INSTRUCTIONS
Please complete all information on the reverse of this form, and follow the instructions below. One form may be
used for multiple expenses. You may mail or fax your request to us, or you may submit your claim electronically
atPacificSource.com/PSA. If you have a question or need assistance in filing this form, you are welcome to call us at (541)
485-7488 or (800) 422-7038 and we will be happy to assist you.
HEALTH-RELATED EXPENSES (FSA or HRA)
1. After completing the Request for Reimbursement Form, attach a copy of insurance Explanation of Benefits (EOB)
or bills/account histories for services you have received. Documentation submitted must include:
a. The date(s) of service
b. A description of the charge
c. The amount you are responsible for paying (charges less insurance and discounts).
Finance charges and interest fees are not eligible.
2. If a service has been partially covered by insurance, send a copy of the Explanation of Benefits (EOB) received
from the insurance company. Include only the amount you will actually be paying for a service. PacificSource
Administrators cannot reimburse you for amounts that will be paid by insurance.
3. Third party verification is required; therefore, cancelled checks and/or check copies may not be used as
documentation.
4. Please retain originals of the bills/forms submitted for your personal tax records. We store documents
electronically and destroy the originals after processing; therefore, originals will not be returned to you. Incomplete
Reimbursement Request Forms, or those received without proper documentation attached, cannot be processed.
If this happens, you will receive a letter of explanation.
5. In certain instances, statements from your healthcare provider may be necessary to verify the medical necessity
of the procedure or prescription. Please call if you have questions.
SUPPLEMENTAL PREMIUM ACCOUNT EXPENSES
1. After completing the Request for Reimbursement Form, attach a copy of the bill showing the insurance carrier’s
name, period of coverage, and the amount you are responsible for paying. A description of the type of coverage
(such as dental, vision, fire, or ambulance) should be included under “brief description.”
2. Third party verification is required; therefore, cancelled checks and/or check copies may not be used as
documentation.
3. Please retain originals of the bills/forms submitted for your personal tax records. Refer to #4 above for more
information.
DEPENDENT CARE EXPENSES
1. After completing the Request for Reimbursement Form, attach a copy of the bill showing the Provider’s name,
period of service, and the amount you are responsible for paying. Childcare expenses may be submitted for
children up to the age of 13.
2. Third party verification is required; therefore, cancelled checks and/or check copies may not be used as
documentation. If your daycare provider does not provide documentation, you may provide the information on the
front of our Request Form. If they do not provide you with their own form of documentation, your daycare provider
must sign the front of the Request Form where indicated each time you submit a claim. (Photocopied signatures
are not accepted.) In certain instances, statements from your healthcare provider may be necessary to verify the
medical necessity of adult daycare. Please call if you have questions.
3. Please retain originals of the bills/forms submitted for your personal tax records. Refer to #4 above for more
information.
Request for Reimbursement from FSA or HRA_0714
PacificSource.com/PSA
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