FLEXIBLE SPENDING ACCOUNT CLAIM FORM

							                                         HEALTH REIMBURSEMENT ACCOUNT CLAIM FORM
                                                       Mail or Fax to: KCI FINANCIAL SERVICES, INC.
                                                               11011 Sheridan Street, Suite 202
                                                                  Cooper City, Florida 33026
                                                          Tel: (954) 443-4443 * Fax: (954) 443-4445
                                                         Email Claims to: kcifinancialserv@aol.com


                                                                     Request for Reimbursement




Employer:_____________________________________________________________________________________________________

Employee Name: _________________________________________________ Social Security Number: _________________________

Employee Address: _____________________________________________________________________________________________
                                                                                     City                                  State                                   Zip
Please check if new address:




Unreimbursed Medical                          LIST EACH RECEIPT SEPARATELY                               (Use additional forms if necessary)

                         A                                       B                                     C                    D                         E
     Patient Name              Age           Provider Name                  Description of Service            Date of Service       Requested Amount of            KCI Use Only
                                                                                                                                      Reimbursement




Please attach a third-party receipt, itemized bill AND an Explanation of Benefits (EOB) listing (A), (B), (C), (D) and (E).
Cancelled checks, credit or debit card receipts or bills showing a previous balance or balance due are not acceptable.




I request reimbursement from my Health Reimbursement Account as listed above and certify that these are eligible Medical Expenses that I or my dependents have incurred.
I understand that medical expenses must qualify as deductible expenses for Federal Income Tax purposes, and cannot be reimbursed by any other source or used as a
deduction on my personal income tax return(s). I furthermore affirm that I (or my dependents, if covered) have incurred at least the first $ ____________ of the calendar year
deductible stipulated in my employer’s group health plan.




Date: __________________                                                        Employee Signature: __________________________________________