For Internal Use Only: Plan Year 1 Plan Year 2
HEALTH CARE REIMBURSEMENT ACCOUNT CLAIM FORM
Note: For First Time Orthodontics Claim, also see Orthodontic Worksheet
EMPLOYEE: ____________________________________________________ SOCIAL SECURITY #___________________
EMPLOYER:____________________________________________________ Email:_________________________________
HOME ADDRESS:__________________________________________________________________________________________
Please X if new address Street/Apt No. City State Zip
HOME PHONE:_______________________________________________ WORK PHONE:__________________________
The following documentation must accompany this claim form:
If expense is: Attach:
Itemized receipt must document:
(
/Cancelled checks are not acceptable receipts)
Covered by insurance
Explanation of Benefits (EOB)
¾ Date service was performed
(including amounts applied to deductible)
¾ Description of service
Not covered by insurance
Itemized receipt ¾ Service provider’s name
Office visit co-pay Itemized receipt ¾ Service provider’s address
Prescription co-pay Itemized receipt ¾ Person for whom service was provided
¾ Out-of-pocket cost to you
For each expense provide the following information (Remember: Retain a copy of claim form & receipts for your records)
Type of
Expense
Expense
covered
by
insurance
Is this a
Co-
payment
Amount of
Out-of
Pocket
Expense
For Office
Use Only
Date of Service
Medical
Prescription
Vision
Dental
OTC
Yes
No
Yes
No
Description of Service
or
Comments
(Optional)
Adjust
1
2
3
4
5
6
7
CERTIFICATION:
Total of claims
$
I certify the expenses on this Claim Form:
BRI adjustments
• are accurate and true
BRI claims paid
• are for a person covered under this Plan
• are eligible expenses which have not been previously reimbursed under this or any other benefit plan
• will not be claimed as an income tax deduction
Employee Signature:_____________________________________________ Date:__________________________________
I hereby authorize Benefit Resources, Inc. or its representatives to obtain information from all physicians, hospitals, medical service providers, pharmacists,
employers, and all other agencies or organizations (this includes other insurers) to consider the claim for reimbursement from my Flexible Spending Account.
Benefit Resources, Inc.
4775 E. 91st Street, Suite 100 Tulsa, OK 74137-2805
Phone: (918) 481-6161 1 (800) 339-7493 (Toll Free)
Fax: (918) 481-6181 1 (866) 364-7052 (Toll Free)
www.britulsa.com
You may email scanned claims to:
claims@britulsa.com
H:\COMMON\Forms and Links\Section 125\For Gail\URMclaim5.08.06.doc
