NEW YORK STATE FLEX SPENDING ACCOUNT
A State employee benefit that puts money in your pocket
 Plan Year:  __________
REIMBURSEMENT REQUEST FORM  -  HEALTH CARE SPENDING ACCOUNT
SECTION A
Name:

 

 Home Phone:

(          )

 Work Phone:

(          )

 SSN:
Street Address:

 
City:

 

 State: Zip:
SECTION B
Do you have coverage for medical expenses? YES checkbox     NO checkbox
Is your medical coverage provided through an HMO plan? YES checkbox     NO checkbox
Is any portion of the service covered by your medical coverage? YES checkbox     NO checkbox
Was the amount applied to your deductible? YES checkbox     NO checkbox
Was the amount you paid a copayment? YES checkbox     NO checkbox
SUMMARY OF HEALTH CARE SPENDING ACCOUNT EXPENSES DATES OF SERVICE:1
Name of Person Receiving Services Relationship to Employee Name and Address of Provider of Services2 Deductible or Co-Pay From
MO/DA/YR		 To
MO/DA/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.
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.
Employee Signature:
 		 Date:
FOR OFFICE ONLY
Date
Authorization #
Initial