FSA/HRA REIMBURSEMENT CLAIM FORM

(Please Print Clearly)

PART 1

PART 2

Check here if address has changed and provide new information below.

Employee Name:

Street or P.O. Box:

Member ID:

City:

Employer:

State:

Zip Code:

PART 3

Provider & Service Rendered/Item Purchased

*Pay from

Prior PY?

Date(s) of Service

Amount

For Office Use Only

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

Employee Certification:

I request reimbursement for Medical and/or Dependent Care expenses as

Í

TOTAL

indicated above. Enclosed are itemized bills, receipts or EOBs verifying these expenses. Each expense

listed is for a service/item provided to me, my spouse or an eligible dependent, has not been purchased with

a Beniversal®

card, and will not be reimbursed from any other source. Medical expenses were incurred

only for an immediate medical purpose. I understand that these expenses must qualify for reimbursement

under the Internal Revenue Code and that they cannot be claimed as credits or deductions on my personal

income tax.

Signature:

Date:

ATTN: Claims Department

Benefit Resource, Inc.

2320 Brighton-Henrietta TL Rd.

Rochester, NY 14623

Fax: (585) 427-9320

*If your Plan offers the extended grace period allowed by IRS regulations, you must check Yes if you wish to have this expense reimbursed from the prior Plan Year.

INSTRUCTIONS FOR SUBMITTING YOUR CLAIM:

1. Part 1 of the claim form

must

be completed in full.

2. Part 2 of the claim form should only be completed if your address has changed.

3. Part 3 of the claim form

must

be completed in full.

4. For each item you are claiming in Part 3, you must attach a copy of itemized bills, statements, receipts or insurance company Explanation of Benefits (EOBs). This

documentation from your provider

must

include the following information

(please retain originals for your personal records)

.

• Name of provider

• Your out-of-pocket cost for the service

• Date(s) service was provided

• Name of person receiving the service

• Type of service provided (for prescriptions, must include name of drug)

IRS regulations may require additional documentation for certain expenses (e.g. for dual purpose items).

5. The claim form

must

be signed and dated after reading the Employee Certification.

6. Submit the completed claim form and related documentation to:

ATTN: Claims Department

Benefit Resource, Inc.

2320 Brighton-Henrietta TL Rd.

Rochester, NY 14623-2782

Fax: (585) 427-9320

C

LAIM SUBMISSION REMINDERS:

• Credit card statements, cancelled checks and balance forward/prior balance statements

are not

acceptable.

• The service being claimed must be provided within your Plan Year to you, your spouse or your dependent.

• In general, IRS regulations do not require that you pay for a service before requesting reimbursement. A request for reimbursement must be based on the date when the

service was provided, not the date when a payment was made. (The IRS allows one exception: orthodontia expenses can be based on date of payment, date of service or

payment due date on statements/coupons.)

• Claims must be submitted

after

a service is provided, but

before

the end of the run-out period following the end of your Plan Year.

• Claims must be received by Benefit Resource, Inc. within the timeframes specified in the Plan Highlights.

• The expense being claimed cannot be reimbursed from any other source.

S

OME EXPENSES THAT ARE

NOT

ELIGIBLE FOR REIMBURSEMENT FROM A MEDICAL REIMBURSEMENT ACCOUNT INCLUDE:

• Personal care items (e.g. shampoo, soap, electric toothbrush, toothpaste, mouthwash)

• Teeth whitening

• Insurance premiums

S

OME EXPENSES ARE

ONLY

ELIGIBLE FOR REIMBURSEMENT FROM A MEDICAL REIMBURSEMENT ACCOUNT IF CERTIFIED BY A LICENSED MEDICAL PROVIDER AS

PREVENTING, TREATING, OR MITIGATING A SPECIFIC PHYSICAL DEFECT OR ILLNESS:

• Cosmetic services

• Vitamins

• Nutritional and dietary supplements

• Non-prescription sunglasses

• Exercise and weight loss programs

Rev. 10/07

Phone: 1-800-473-9595

FSA/HRA 200-8

Website: