Section 125 Claim Form
Send to: ISTA Administrative Services Corporation, 150 W. Market St., #757, INDPLS, IN 46204
(Please check if this is a new address ❑) Participant’s Social Security # __________ __________ __________
School Corporation _________________________________________________________________________________________
Last First MI
Street __________________________________ City _______________________________ State __________ Zip _________
Home Phone ________________________________________ School Phone ________________________________________
E-Mail Address ____________________________________ Electronic Notification will be sent to this address upon processing of this claim. You may add or
update your e-mail address by accessing our website below.
Non-Reimbursed Medical Claims
Relationship to Participant Date Service Performed Requested Amount
Patient Name Provider Name Description of Service of Reimbursement
Self Spouse Child Other Month Day Year
For expenses that are not eligible under your insurance, attach a receipt or itemized bill showing the date of service, type of service, and requested reimbursement amount. Cancelled checks or
bills showing only balance due are not acceptable.
Dependent/Child Care Claims (If your provider signs and completes the following, no other receipt is required.)
Effective January 1, 1989, the I.R.S. requires the dependent/child care provider(s) to furnish the provider’s current name, address, Tax Identification Number (or Social Security Number) to the
taxpayer making claim, unless the provider is exempt from federal income taxation as described in I.R.C. Section 501(c)(3). A provider failing to comply with this law is subject to $50 fine for
each such failure unless proven that failure is due to reasonable cause, not willful neglect.
The dependent care information including provider(s) name, address, TIN/SSN is correct to the best of my knowledge. I understand I may incur penalties of perjury if the information is know-
ingly misstated. (Signed below by provider(s).)
Name of Dependent Dates Care Requested Amount
Receiving Care Age Provider Signature Provider Address TIN/SSN Provided of Reimbursement
I request reimbursement from my Section 125 Flexible Benefits Plan as listed above and certify that these are legitimate expenses, which
I or my dependents have incurred. I understand expenses must qualify as deductible expenses for federal income tax purposes and
cannot be reimbursed by any other source or used as a deductible on my personal income tax return(s).
Date Participant’s Signature
Indianapolis Area (317) 616-0123 — Toll Free 1-800-344-1915
Interactive Voice Response - 1-877-478-2487
Fax (317) 655-3738 — Toll Free Fax 1-877-655-3738
Web site - http://www.istafsp.org/flexlogin.htm
How to File a Section 125 Claim
1. Complete the reverse side of this form, being sure to sign and date it. The claim will be returned without this infor-
2. If you carry group insurance submit expenses to the insurance carrier.
3. If you do not carry group insurance submit itemized bills and/or receipts which indicate:
• Name of patient;
• Type of service or supplies provided and the related expenses;
• Date of service and/or expense;
• Name and address of provider(s) and/or supplier(s).
4. Have your dependent care provider complete and sign the reverse side of this form. Additional child care receipt is not
To qualify for reimbursement, expenses must be incurred during the plan year for which you are requesting reimbursement.
A list of qualifying expenses is included in your enrollment kit.
1. Non-Reimbursed Medical Account 2. Dependent/Child Care Account
Can be used for medical expenses for you or your family Reimburses for care of your child or other dependent while
which are not covered by any other health plan. Items cov- you are at work. Specifications for this account are:
ered include, but are not limited to: • Your child must be under age 13.
• Deductibles/Co-Insurance • Your dependent over age 13 must be incapable of self
• Medical, Dental, Vision Care Services
• Individual caring for your child under age 13 must not be
• Hearing Aids and Exams dependent upon you for support.
• Reimbursement cannot exceed $5,000 annually of your
and/or your spouse’s earned income.
Claim for Reimbursement
(Please refer to the booklet you received from your American Fidelity Assurance representative for more infor-
mation regarding administration of the Section 125 plan.)
Eligible claims for reimbursement are processed daily. Checks are issued according to the agreement with your employer.
You may only be reimbursed for eligible expenses that you and/or your dependent(s) incur on and/or within the dates of your plan
You are provided a sixy-day (60), generally, run-out period within which you may make claims for eligible expenses incurred on
and/or within your plan year dates. The run-out period begins on the last day of your plan year.
If your employer allows the grace period extension, please note you will be allowed to file expenses incurred within seventy (70)
days following the end of your plan year to apply to the preceeding years individual forfeiture amount. THE GRACE PERIOD
EXTENSION WILL ONLY APPLY TO THE MEDICAL EXPENSE REIMBURSEMENT ACCOUNT. The run-out period provid-
ed for the medical expense account will change from sixy days (60) after the plan year ends to twenty days (20) after the seventy day
(70) grace period ends.
Please refer to your Flexible Benefit Plan (FBP) or contact your employer for grace period information.
The medical expense reimbursement check will be for eligible expenses (health, dental, vision not covered by insurance) claimed and
received in our offices prior to the claim submission deadline. The medical expense reimbursement check will be for eligible expenses
claimed up to the maximum annual benefit amount elected at the time of enrollment. Orthodontia and pre-natal expenses are adminis-
tered differently. Please contact an ISTA Administrative Services Corporation Section 125 representative at 1-800-344-1915 for more
information about the administration of pre-natal and orthodontia expenses.
The dependent/child care expense reimbursement check will be for eligible expenses claimed and received in our offices prior to the
claim submission deadline. The check will be for eligible expenses claimed up to the received dependent/child care contribution amount
elected at the time of enrollment. The reimbursement check will not be an amount in excess of the received contribution unless funds
from one or more previous contribution receipts remain unclaimed. If the submitted eligible expenses exceed the monthly contribution
amount, then the remaining unpaid claim will be carried over into the next month(s) until paid in full during the plan year period. If there
is no claim made against the account for one or more months, then the value of your account will be the product of your scheduled depen-
dent/child care contribution times the number of unclaimed months.