Please Send Completed Form With Receipts To:
CDH Administration
40 Commercial Way, E. Providence, RI 02914
Email: BCBSRIclaims@londonhealthusa.com
Fax: 401-435-3937
Spending Account Reimbursement Claim Form
Employer Name:
Employee Name:
If Dependent, Name:
Phone:
Employee ID #:
Health Care Expense Claims: (HRA and/or FSA)
Account Type Date of Service Provider Name Provider Phone # Service Provided Amount Requested
HRA - FSA
Total Amount Requested:
Dependent Day Care Claims: (FSA Only)
Dependent Name Date of Service Day Care Center Day Care Center Type of Service Amount Requested
From----To
(Day Care, Pre-K, Day Camp, Etc.)
I
I
I
I
I
Total Amount Requested:
Transportation Expense Claims: (FSA Only)
Expense Type Date of Service Location Mode of Transportation Description of Expense Amount Requested
Parking---Transit From----To
(Mass Transit, Bus, Commuter, Etc)
I I
I I
I I
I I
I I
Total Amount Requested:
I certify that the above information given by me in support of this claim is true and correct.
Member's Signature: Date:
Plan Administrator
: London Health Administrators Timely filing: All reimbursement requests must be sent within 90 days of the service
date unless London Health determines that unusual circumstances warrant a delay.
Please Send Completed Form With Receipts To:
C
DH Administration
40 Commercial Way, E. Providence, RI 02914
Email: BCBSRIclaims@londonhealthusa.com
Fax: 401-435-3937
For Questions please call:
Local: 401-459-5000
Out of State: 1-800-639-2227
date unless London Health determines that unusual circumstances warrant a delay.
Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association
