REQUEST FOR REIMBURSEMENT FORM

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					                                     REQUEST FOR REIMBURSEMENT FORM
                                           Health Care Account
                                                   EMPLOYEE INFORMATION
                Please type in the required information, print out this form, sign and date it, and return it to
             Partners Benefits Office, 101 Merrimac St., 5th Fl., Boston, MA 02114, or fax it to 617-724-3784.
                             If you have questions, please call the Benefits Office at 617-726-8133.

                        Employee Name

Entity:   BWH        BWPO        MCL       MGH       MGPO          NSMC     PHC       PHS      SKR     SRH   FKH      NWH

Employee No.                                         Work Phone:                                  Home Phone:
   Please complete the appropriate claim information and attach proof of your expenses (bill, invoice, etc.)




                        Description of           Date of                  Amount Paid
                                                               Total Amount                            Amount of
                        Services                 Service       of Service by Your Health               Requested
                                                                          Insurance                    Reimbursement

                                                               $                $                      $
                                                               $                $                      $
                                                               $                $                      $
                                                               $                $                      $
                        Total Expenses:                                                                $

         I understand that I have an outstanding account balance from the prior year. However these
       expenses, incurred between January 1 through March 15, should be reimbursed from my
       current year account. Please check, if electing.

I request reimbursement for the expenses itemized above. I certify that I have not already requested reimbursement for
these expenses under this Plan, or from any other source, nor will I do so in the future. I further certify that I have met
all of the requirements for eligible health care expenses as described in the Reimbursement Plan materials. I understand
that I do not have the opportunity to claim reimbursed expenses as deductions on my personal income tax return. I
understand that in order to be reimbursed for services between my enrollment date in the plan and the end of the plan
year (any expenses through December 31 of each year or the plan termination date), my claim must be received no later
than March 31 of the following year. If this claim is received prior to March 31 of the current year and is for services
incurred prior to March 15 of the current year and you have money remaining in your prior year's account we will
automatically use the balance of your prior year's deferral to pay this claim. Expenses incurred after March 15 of the
current year will be paid with deferrals from the current year.

Signature             __________________________________________________________                        Date ____/ ____/ ____
                       (Please print out, sign and date.)

HEALTH CARE ACCOUNT EXPENSES
       • Expenses covered by your medical or dental insurance plan must be submitted to the plan before you request reimbursement.
           Attach a copy of the Explanation of Benefits Statement to claim the amounts not paid by your plan.

       • Bills must list Provider of Service, Service Provided, Date(s) of Service and Patient Name.

Eligible Expenses: Prescription Drugs, Medical Co-Payments, Eye Glasses, Eye Exams, Contact Lenses, Acupuncture, Chiropractic
Services, Dental Treatment (Non-Cosmetic), Birthing Classes, X-Ray Fees, Over-the-Counter Medications

Ineligible Expenses: Cosmetic Procedures/ Surgery, Teeth Whitening Procedures/ Products, Insurance Premiums.

*For more information, visit the Flexible Spending Accounts website: http://hcet.ebia.com/partners             Rev. 4/09

				
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