Health Reimbursement Account (HRA) Reimbursement Request Form by que48750

VIEWS: 116 PAGES: 1

									                                                        Health Reimbursement Account (HRA)
                                                                  Reimbursement Request Form
Employer Name


Participant First Name                                       MI         Last Name


Address



City                                                                                           State             Zip Code



Email Address



Social Security Number / Member ID                                      Phone Number

                   -               -                                                       -                      -

                                       Date of                                                           Claim         EBS-RMSCO
        Claimant Name                                Amount                Type of Service
                                       Service                                                           Ref #          Use Only
                                                                     Medical    Vision     Dental
                                                                                                            01
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            02
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            03
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            04
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            05
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            06
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            07
                                                                     OTC        Rx

                                                                     Medical    Vision     Dental
                                                                                                            08
                                                                     OTC        Rx


• For each claim, attach Explanation of Benefits (EOB), and/or       payment.
    itemized bill showing: date of service, provider name, patient • Submit one expense (either product or service) per row, even if
    name, charged amount and description. Do not send credit         items are contained on the same receipt. Each item must be
    card receipts or cancelled checks.                               itemized and must have a corresponding receipt. Label receipts
•   Please be sure to provide your SSN or Member ID.                 to correspond to “Claim Ref #”. If you have more than 8 items
                                                                     to submit, use additional Reimbursement Request Forms. Note:
•   Mail to EBS-RMSCO, Inc., FSA Dept, PO Box 22999 Rochester,       Please do not “lump” or group items together or write “see at-
    NY 14692.                                                        tached”. EBS-RMSCO, Inc. can only process claims that are prop-
•   For faster reimbursement processing, submit your claims on-      erly submitted. Claims will be returned to you unless they are prop-
                                                                     erly submitted.
    line at www.myebsaccount.com.
•   If covered by insurance, submit EOB or bill showing insurance
                                                                   • Call Customer Service with questions at 800-327-7130.


By submitting this form to EBS, I certify that the information here is true and correct, that the expenses incurred were for myself,
spouse or qualified dependents and that these expenses are not reimbursable under any other plan coverage.
                                                                                                                            HRA_Reimb_2009 (FSA13)

								
To top