Reimbursement Request Form
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DO NOT RETURN THIS INSTRUCTION PAGE WITH YOUR REIMBURSEMENT FORM RETURN THIS • Please enter the requested information for your claim to be considered for reimbursement.
• Each claim item should be entered, itemized per receipt or documentation, in the same order you are enclosing
the documents.
• PLEASE NUMBER THE TOP OF THE FOLLOWING PAGE(S) WITH THE CLAIM ITEM #.
• Provide legible supporting documentation from an independent 3rd party for your claim (i.e. receipt, doctor’s bill,
or Explanation of Benefits (EOB)), which must include:
o Date of service or sale date of the eligible product (must match claim details entry below)
o Name of person or organization that provided the service or product
o Type of service provided or description of eligible product
o Amount of expense (the portion you are responsible for paying)
• Sign and date the Request Form. Forms without a signature will not be accepted or processed.
HELPFUL HINTS
• Do - Keep documentation in order (e.g. number the top of the page with the claim line item #), circle
applicable items on the documentation enclosed, tape small receipts to a full sheet of paper, use as many sheets
for additional expenses, indicate whether you or your dependent incurred the expense under
“Claimant.”
• Do Not - Include credit card receipts/statements or canceled checks, highlight any part of the documentation,
staple multiple receipts to the form or sheet of paper, mail the same form after you faxed or emailed it.
• Reference the following Plan Type - F = Health FSA, D = Dependent Care FSA, H = HRA, P = Parking, T = Transit
• If you are submitting an HRA expense, make sure you are aware of the HRA Plan Design and any requirements of
the type of documentation we need in order to process your claim (i.e. if you’re only reimbursed for
deductible expenses, the documentation provided must indicate the expense was applied towards
deductible).
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