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  HEALTH CARE SPENDING ACCOUNT
REIMBURSEMENT REQUEST FORM		 Plan Year:  __________
SECTION A
Name:

 

 Home Phone:

(          )

 Work Phone:

(          )

 SSN:
Street Address:

 
City:

 

 State: Zip:

SECTION B
SUMMARY OF HEALTH CARE SPENDING ACCOUNT EXPENSES DATES OF SERVICE:1
Name of Person Receiving Services Relationship to Enrollee Name and Address of Provider of Services2 From
 MO/DAY/YR 		 To
 MO/DAY/YR 		 Amount to be Reimbursed
 

 

 

  

 
 

  

 
 

  

 
 

  

 
 

  

 
 
 

 

 

  

 
 

  

 
 

  

 
 

  

 
 

  

 
 
 

 

 

  

 
 

  

 
 

  

 
 

  

 
 

  

 
 
 

 

 

  

 
 

  

 
 

  

 
 

  

 
 

  

 
 
 

 

 

  

 
 

  

 
 

  

 
 

  

 
 

  

 
 
 

 

 

  

 
 

  

 
 

  

 
 

  

 
 

  

 
 
1  Use dates on which service was provided, not the date you paid for it.
 2  "Provider" means hospital, doctor, dentists, drugstore, medical supply store, etc.		 Total Amt To Be Reimbursed: $_____________
The above information is a true and accurate statement of unreimbursed medical expenses provided to me or my eligible dependents on the date(s) indicated. I have read and understand the HCSA reimbursement instructions. I understand that I am responsible for misrepresentation regarding requests for reimbursement.
Enrollee Signature:
 		 Date:
FOR OFFICE USE ONLY
Date
 		 Authorization #
 		 Initial
 
NEW YORK STATE FLEX SPENDING ACCOUNT
A STATE EMPLOYEE BENEFIT THAT PUTS MONEY IN YOUR POCKET