Over the Counter Drug Claim Form
Do NOT use this form for prescription drugs.
Employer Name:
Fax your Claim to:
Local Fax: 251-666-0101 Toll Free Fax: 800-329-3539 PLEASE DO NOT SEND A SEPARATE COVER SHEET Problems Transmitting? Call FlexComp at:
Employee Name:
Employee SS#:
Sender’s Phone:
LOCAL PHONE: 251-666-1999 Toll Free Phone: 800-340-8077
Total Pages Submitted: Instructions for Claiming Over the Counter Drugs • Provide the information requested below. • Attach proof of your expenses (ie cash register receipt with the name of the item and the amount charged) • Read the statement at the bottom of the form. If you agree, sign the statement and fax it to FlexComp. You may mail your claim to FlexComp, P. O. Box 91566, Mobile, AL 36691-1566. Purchase Date Name of Item For the Treatment of: Total Expense
Total OTC Expenses: By my signature below, I hereby certify that: • All the expenses listed above were incurred on the date shown and while I was a covered participant in the above named employer’s Cafeteria Plan Medical Reimbursement Flexible Spending Account; • All items listed above were for use by me or by my covered dependents; • I am fully responsible for the sufficiency, accuracy, and veracity of all information relating to this claim; • I will not seek reimbursement from any other health care benefit, and I may be liable for payment of all taxes on amounts paid from the plan if the expenses claimed are not proper expenses. ________________________________________________ Employee Signature ___________________ Date
phone: 251.666.1999 800.340.8077
p.o. box 91566 mobile, al 36691-1566
fax: 251.666.0101 800.329.3539