Florida combined insurance agency (fcia)
Flex Spending Reimbursement Request
PLEASE MAIL CLAIMS TO: / FLORIDA COMBINED LIFE
PRETAX DEPARTMENT
P. O. BOX 45132
JACKSONVILLE, FLORIDA 32232-5132 / TOLL FREE NUMBER: 1-800-434-8026
INSTRUCTIONS (More detailed instructions on second page)
BOTH SIDES OF FORM MUST BE COMPLETED ALL ITEMS Ö OR IN RED MUST BE COMPLETED
PLEASE PRINT (Do not alter this form in any way)
Dependent (Day) Care Expenses - If you are requesting day care reimbursement, you may use this form as your day care receipt, by completing the Day Care Provider Information section on the reverse. Then have your day care provider sign the provider’s line AFTER validating the information you complete. Or, you may attach a detailed receipt from your day care provider to the BACK of this completed form. That receipt must show the provider’s name, phone number, address, tax I.D. number, the name of the person for whom care was furnished, the service dates, and the amounts charged for each service period.
Generic “cash receipts” are not adequate.
Health Care Expenses - If you are requesting health care reimbursement, you must complete the Reimbursement Expenses section on the reverse. If not insured, you must submit original receipts indicating services rendered, date of service, for whom the service was provided, and all charges. If insured, you must submit your insurance company’s original statement, called an Explanation of Benefits (EOB), which indicates patient responsibility. (HMO insurance does not provide EOB’s, therefore, original receipts are required to receive payment for your medical expenses.)
Copies, balance forward/due or generic “cash receipts” are not acceptable.
Ö INSURANCE INFORMATION (Must be completed or claim will be returned)
ONLY APPLICABLE IF FILING FOR MEDICAL REIMBURSEMENT
Name of Health Insurer Coverage type:
None HMO PPO Traditional (Indemnity) Prescription Vision
Are dependents also covered? Yes No
Name of Dental Insurer Coverage type:
None HMO/Prepaid/Discount Plan PPO Traditional
Are dependents also covered? Yes No
Ö DEPENDENT INFORMATION
COMPLETE ONLY IF CLAIM IS FOR A SERVICE PROVIDED ON A DEPENDENT
Are any of your dependents college students under age 25? Yes No
Do dependent(s) live in your household?
Yes No / Do you provide more than one-half of the support for the dependent(s) during the year? Yes No
PLEASE COMPLETE AND RETURN BOTH SIDES OF THIS FORM
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STAPLE RECEIPTS TOREVERSE SIDE / HEALTH CARE AND/OR
DEPENDENT (DAY) CARE EXPENSES
PLEASE PRINT (Do not alter this form in any way) / ALL ITEMS Ö OR IN RED MUST BE COMPLETED
Ö / Employee’s Name - Last / First
/ Ö / Social Security No.
Ö / Company Name/parent company if subsidiary/Leasing Company
I request reimbursement of the following HEALTH CARE EXPENSES and/or DEPENDENT (DAY) CARE EXPENSES that qualify under the Plan. (Please be sure to select “H” for Health Care or “Dep” for Dependent Care in the column below: Please identify the day care provider by selecting provider “A” or “B” below. If you do not have enough room on this sheet, please add a separate sheet, itemizing all expenses, following the format below.)
Ö REIMBURSEMENT FOR HEALTH CARE AND/OR DEPENDENT (DAY) CARE EXPENSES
Patient
or / Relation-
ship / Type of
Expense / Day Care
Provider / Date of Service **
(MONTH/DAY/YEAR)
Dependent’s
First Name / to Employee / Age / (Circle)
(H or Dep) / (Circle)
(A or B) / From
(MMDDYY) / To
(MMDDYY) / Description of Expense / Amount / For FCL
Use Only
H or Dep / A or B / $
H or Dep / A or B / $
H or Dep / A or B / $
H or Dep / A or B / $
H or Dep / A or B / $
H or Dep / A or B / $
H or Dep / A or B / $
**Service must be totally rendered and completed before payment on any part can be made. / TOTAL / $
Ö DAY CARE PROVIDER INFORMATION
(A) Provider of Day Care
/ (B) Provider of Day Care
Address of Day Care Provider
/ Phone No.
/ Address of Day Care Provider
/ Phone No.
Federal Tax ID/Social Security No.
/ Date
/ Federal Tax ID/Social Security No.
/ Date
Signature of Day Care Provider (Please sign only after validating service dates & amounts) / Signature of Day Care Provider (Please sign only after validating service dates & amounts)
Complete the information below on Provider of Day Care:
If Provider is related to Participant, can he/she be claimed on Federal Income Tax of Participant? Yes No
Age: ______Relationship to Participant: ______/ Complete the information below on Provider of Day Care:
If Provider is related to Participant, can he/she be claimed on Federal Income Tax of Participant? Yes No
Age: ______Relationship to Participant: ______
If the Dependent is disabled, please identify disability and provide name and address of certifying physician.
Ö EMPLOYEE SIGNATURE - (Must be signed or claim will be returned)
I certify that all expenses for which reimbursement or payment is claimed by submission of this form, were incurred during a period while I was covered under my company's Flexible Benefits Program with respect to such expenses; and that such expenses have not been reimbursed, and are not reimbursable, under any other health plan coverage. I understand that I alone am fully responsible for the sufficiency, accuracy and veracity of all information I provide relating to this claim; and that unless an expense for which reimbursement is claimed is a proper expense under the Plan, I may be liable for the payment of all related taxes including Federal, state or city income on paid amounts which relate to such expense. I further understand that no separate Federal income tax deduction or credit is permitted for amounts for which reimbursement is made.
I hereby authorize any individual or organization to release any information requested by FCL with respect to this specific application.
/ Employee
Signature: / Daytime Phone
Number: /
/ Date: /
FOR FCL USE ONLY
Processor's Name:______/ Claim No.: ______/ Date Processed: ______
/ DEPENDENT (DAY) CARE EXPENSES
GUIDELINES FOR FSA DEPENDENT (DAY) CARE REIMBURSEMENTS
Complete the Reimbursement Expenses section to obtain
dependent (day) care reimbursement
· To be eligible, your child and dependent (day) care expenses must be incurred as a result of your working or looking for work. If married, your spouse must be:
Ö employed and earn income from work during the year, or
Ö a full-time student for at least five months during the year, or
Ö disabled and unable to provide for his or her own care.
· Eligible dependents include dependent children under age 13, or, a person who may be claimed as a dependent (child over age 13, spouse, parent) who is physically or mentally unable to care for himself or herself. The qualifying person must spend at least 8 hours per day in your household.
· Eligible expenses - You can be reimbursed for certain expenses you have on days you (and, if married, your spouse) work and also pay someone to care for your dependents. These include:
Ö nursery schools and day care centers for preschool children, or
Ö individuals - other than your dependents - who provide care for your children in or outside your home, or, for your disabled older child, disabled spouse or disabled dependent parent in your home.
· Eligible payments to relatives as day care providers:
Ö You can claim work-related expenses you pay to relatives who are not your dependents, even if they live in your home. However, do not claim any amounts you pay to: 1) a dependent for whom you (or your spouse if you are married) can claim an exemption, or 2) your child who is under age 19 at the end of the year, even if he or she is not your dependent.
· You cannot claim the IRS income tax deduction or credit for any dependent (day) care costs paid from your reimbursement accounts.
HINTS FOR QUICKER RETURN OF REIMBURSEMENT
· Dependent Care claims can only be paid after the service has been fully rendered. We encourage you to break the service dates down into weekly periods, on your claim form or receipt, to expedite payment for actually incurred services.
· The only acceptable documentation will be an itemized imprinted statement from the day care provider showing the provider’s name, phone number, address, tax I.D. number, the name of the person for whom care was provided, the service dates, and the amounts charged for each service period.
· If the day care provider cannot furnish an itemized imprinted statement, then the FCL Flexible Spending Reimbursement Request form must be used as a receipt. The provider must sign and date the claim form after you complete it.
· On the form, there are two sections for provider information, A and B, for children who receive separate day care. Please circle A or B by your child’s name in the reimbursement expense section to identify the involved provider.
· Please complete the claim form with the name, relationship, age, and disability of your dependent, plus dates of service from and to, and the amount you paid. Always complete the entire provider section even though you may have given us this information previously.
ê OVER FOR HEALTH CARE INSTRUCTIONS ê
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HEALTH CARE EXPENSESGUIDELINES FOR FSA HEALTH REIMBURSEMENTS
Complete the Reimbursement Expenses section to obtain health care reimbursement
Dependents:
· Eligible dependents - Include dependents who qualify as dependents as defined by the Internal Revenue Service.
· Eligible expenses - Include health care expenses, i.e., plan deductibles and co-payments, plan exclusions, such as routine physicals or vision and hearing. The expenses must qualify as an IRS recognized income tax deduction that cannot separately be taken as a deduction if they are reimbursed through this account.
Supporting Documentation:
· Traditional or PPO-type insurance: All charges must first be submitted to your health and dental insurers. Please attach to this claim form, the insurance company’s ORIGINAL EXPLANATION OF BENEFITS, showing patient responsibility.
· HMO-type insurance: Please attach to this claim form, the ORIGINAL DETAILED DOCTOR’S STATEMENT, showing patient’s name, date of service, service types, and the co-pay amount.
· No insurance: Please attach to this claim form, an original detailed doctor’s statement, showing patient’s name, date of service, service types, and the amount of the expense.
HINTS FOR QUICKER RETURN OF REIMBURSEMENT
· The Explanation of Benefits (EOB) or original receipt (no insurance or HMO) must show service date and type of service performed. “Balance Forward/Due” statements are not acceptable documentation.
· Claims are ordinarily reimbursed based on the incurred service date and not the date of payment.
· Cosmetic services, such as tooth bleaching and bonding, are not legally eligible for reimbursement unless prescribed in writing as medically necessary by your doctor or dentist.
· Please staple all ORIGINAL receipts (no insurance or HMO) or EOB’s (PPO/Traditional insurance) to the BACK of the claim form where indicated at the top left-hand corner of the “Health Care And/Or Dependent (Day) Care Expenses” page.
· Use our pre-addressed claim envelope to mail your claim.
· Remember to include your company/parent company if subsidiary or Leasing company’s name in the designated area at the top of the claim form.
· Your health care annual election is available for spending in its entirety, the first day of the plan year. You do not have to wait for your payroll deductions to equal your claim amount before you file. The run out period is intended to be used only by those individuals who have medical services very late in the plan year and must file with their health insurer first, to obtain the EOB that must be filed with the FSA claim. If your claim does not fall into this category, please do not hold your claim until the end of the plan-year run out period. You risk forfeiting your funds if any unresolved issues remain when the run out period ends. If you must file during the run out period, your claim must be POSTMARKED by the last day of the run out period. File early and regularly throughout the plan year.
· Remember to sign your claim form!
ê OVER FOR DEPENDENT CARE INSTRUCTIONS ê /
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