Fillable Nbs-flex-spending-claim-form 2011 Enrollment Packet (EE Pay - Educators).xlsx

Fill Online, Printable, Fillable, Blank Nbs-flex-spending-claim-form 2011 Enrollment Packet (EE Pay - Educators).xlsx Form

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Nbs-flex-spending-claim-form 2011 Enrollment Packet (EE Pay - Educators).xlsx

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EmployeeSignature Date
NBS‐402
(
10/10
)
FlexibleSpendingAccount(FSA)ClaimForm
Personal
Information
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DateofService ServiceProvider
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ForAccountBalance:GoTo
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ene
fi
ts.com
Attachacopyofsupportingreceipts,vouchers,bills,etc.
OrCall
Allreceiptsmustdetaileachoftheitemssummarizedbelow
(801)838‐7324or(888)353‐9125
Pleaseprintindarkblueorblakinkwhenusingthisform
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Mail:NationalBenefitServices,LLCP.O.Box6980,WestJordan,UT84084
FAX:
SaltLakeCityAreaFax:(801)355‐0928TollFreeFax:(800)478‐1528
Email:
claims@NBSbenefits.com(PDF,TIFForJPEGfilesonly)
HealthCare
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**Notice**
EffectiveJan.12011
allover‐the‐counter
(OTC)medication
claimsmustbe
accompaniedbya
prescriptiontobe
eligibleundernew
federalregulation
Southern Utah University
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Nbs-flex-spending-claim-form 2011 Enrollment Packet (EE Pay - Educators).xlsx

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Completed 13 February 2020

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