E
XPENSE REIMBURSEMENT VOUCHER FOR
HEALTHCARE FLEXIBLE SPENDING ACCOUNT (HEALTHCARE
FSA)/HEALTH REIMBURSEMENT ARRANGEMENT (HRA)
Name of Employee (Last, First, MI)
Social Security #
Mailing Address
Check here if this is a new address
; if so, do you have other AF products?
E-mail address
Name of Employer
Daytime Phone #
Date of Expense
Name of Person for Whom the
Expense Was Incurred
For an HRA expense, if this person
is/has ever been enrolled in
Medicare, y
ou
must provide their
Medicare C
laim
N
umber
(HICN)*
Amount of Medical Expense
*Section 111 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA) (P.L.
110-173) requires American Fidelity to report certain HRA data to the Centers for Medicare
& Medicaid Services.
Expense Total:
(must be completed)
EXPENSE GUIDELINES: All documentation attached must have a detailed explanation of the date, type, and amount of each
service rendered. Some Employer’s HRA Plans require an EXPLANATION OF BENEFITS (EOB) to be submitted with each
reimbursement request. Check with your Employer for details on your plan.
Acceptable Documentation to accompany the reimbursement voucher: Unacceptable Documentation includes:
Professional bill or receipt that includes: Cancelled checks or credit card receipts
Provider of service Type of service rendered Bill or receipt that only shows a balance forward/
• Charges for the service Original date of service previous balance or payment due
NOTE: the date of service, not the date of payment
must fall within the dates of the plan year for which you are enrolled
Insurance Company Explanation of Benefits
Pharmacy Statement that includes Rx number and name of prescription
Over-the-counter drugs and medicine - medical practitioner’s prescription and receipt required.
I authorize the above expenses to be reimbursed from my account balance. To the best of my knowledge my statements on this form are true
and complete. I certify that either I, my spouse, my tax dependent or my adult child who will be under the age of 27 as of the end of the
calendar year has received the services described above on the dates indicated and that the expenses qualify as valid “medical care expenses”
as defined by Internal Revenue Code Section 213(d). I certify that these expenses have not been reimbursed under this or any other health
plan and I will not seek reimbursement under any other health plan. I understand that the expenses for which I am reimbursed may not be used
to claim any federal income tax deduction or credit. I further understand that I may be asked to provide further documentation or further detail
relating to an expense.
INCOMPLETE VOUCHERS MAY DELAY PROCESSING OR RESULT IN A DENIED CLAIM
Date Signed Signature of Employee
KEEP A COPY OF ALL CLAIMS SUBMITTED FOR YOUR RECORDS
Mailing Address: American Fidelity Assur
ance Company, Flex Account Administration, PO Box 161968,
Altamonte Springs, FL 32716
PHONE NUMBER: 800-662-1113 FAX NUMBER: 844-319-3668
American Fidelity will not be responsible f
or faxes not received. Healthcare FSA average processing time is 5 to 7
working days from receipt of a completed voucher; HRA
average processing time may vary based on plan design.
Rev 0216
$ 0.00
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