For Internal Use Only Plan Year 1 Plan Year 2
I:\Document Master\Master Forms\ProRataOrthoClaim05.08.06.doc V05/08/06
HEALTHCARE EXPENSE FLEXIBLE SPENDING ACCOUNT
Orthodontic Pro Rata Worksheet and Claim Form
EMPLOYER:_________________________________________________________________________________
SSN:_________________________________EMPLOYEE NAME:_____________________________________
HOME ADDRESS:____________________________________________________________________________
Number/Street City State Zip
WORK SITE PHONE:____________________________________HOME PHONE:________________________
⇒THIS FORM NEEDS TO BE COMPLETED ONCE PER PLAN YEAR⇐
Complete this worksheet to pro rate the orthodontic cost over the life of the
orthodontic treatment
1.
Patient’s Name:
___________________________________________
2.
Date appliance installed
____/____/____
3.
Expected date completion of treatment
____/____/____
4.
Number of months of treatment
Count number of months from installation to
completion
_______months
5.
Total cost of treatment
Attach copy of Orthodontic contract
$____________
6.
“Up-Front” costs:
(Examples: X-rays, evaluation and installation.)
Eligible for reimbursement when paid. Submit
documentation with this form or a Healthcare
Reimbursement Claim form.
$(___________)
7.
Insurance reimbursement
Attach Dental Pre Authorization worksheet or
Insurance Explanation of Benefits “EOB”
$(___________)
8.
Expense to be amortized over treatment
Subtract Line 6 and Line 7 from Line 5
$____________
9.
Monthly Expense
Divide Line 8 by Line 4
$____________
The Monthly Expense will be automatically reimbursed to you each month beginning with the first month of treatment (or the first
month of the plan year if this is a continuation of a previous claim) until you have been paid the full amount of your annual election
or the contract ends. No additional orthodontic claim forms need to be submitted.
Under the rules of the Flexible Benefit Plan adopted by your employer, an expense is considered as having been incurred
when the service is provided that gives rise to the expense, and not when the expense is formally billed or paid. An employee
may not be reimbursed in advance for the full cost of an ongoing treatment because the full service has not been completed.
Orthodontist Name: (Please print)____________________________________Phone: ______________
Orthodontist Signature:____________________________________________Date:________________
Attach a copy of the Orthodontic Contract to this form
Employee Signature:_______________________________________________Date:________________
Benefit Resources, Inc.
4775 E. 91
st
Street, Suite 100
Tulsa, OK 74137-2805
Phone: (918) 481-6161 1 (800) 339-7493
Fax (918) 481-6181 (Local) 1-866-364-7052 (Toll Free)
You may e-mail scanned claims to: claims@britulsa.com
