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L ROBERT KIMBALL AND ASSOCIATES

FLEXIBLE BENEFITS ACCOUNT


Reimbursement Request
CLAIMS FILING PROCEDURE
1. Complete this form and submit appropriate documentation. (Incomplete requests will not be processed.)
2. Medical Spending Account Reimbursement Requests must include an Explanation of Benefits (provided by your Health Care Plan Administrator), or an itemized bill
from the provider of services if the service is not covered by your health care plan. Over-the-Counter drugs must show the name of the drug and the date of
purchase.
3. Dependent care receipts from the service provider must include dependent's name, date of service, amount charged, a statement indicating fees were charged for
dependent care, the service provider's signature and tax identification number.
REIMBURSEMENT REQUESTS WILL NOT BE PROCESSED WITHOUT COMPLETE DOCUMENTATION.

Employee: Social Security Number: _____

Type of Claim:
M = Medical
D = Dependent Relationship to Provider Date of Type of Total Amount Health Reimbursement
Care Patient/Dependent Employee of Service Service Service Charges Care Plan Paid Requested

I certify that the expenses for which I am requesting reimbursement meet all of the conditions listed below:
• They were incurred for services and/or supplies received by my eligible dependents or me under the plan.
• They were for services or supplies furnished on or after the effective date of my Flexible Spending Account for additional health care or dependent care expenses.
• I have not been reimbursed for these expenses in any other way nor shall I seek any other reimbursements and I will advise The Loomis Company of any adjustments to health
care plan claim payments which may alter or impact this request for reimbursement.
• Over-the-Counter Drugs meets the definition of “medical care” which is defined as “amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the
purpose of affecting any structure or function of the body”.
I understand that reimbursement of these expenses should be requested and made only after I have collected all benefit payments available from all plans under which my eligible
dependents and I are covered. I further certify that I have not deducted nor will deduct on my individual income tax return any of the expenses reimbursed through my Flexible
Spending Account. I understand that reimbursement will be made in accordance with the provisions of the plan in which I participate. I accept responsibility for the proper treatment of
benefits paid under this plan with respect to eligibility, income tax reporting and liability.

Employee Signature Date

Send to: The Loomis Company, Flexible Benefits Administration, P.O. Box 7011, Wyomissing, PA 19610-6011, (610) 374-4040, Fax: (610) 374-6986.

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