Healthcare & Dependent Care Reimbursement Account Claim Form

What you need to submit with your claim form:

Healthcare Reimbursement Account

• Completed claim form
• EOB statements indicating the deductible, co-insurance and amounts not covered by any medical/dental plans under which the employee or eligible dependents are covered
• Fully itemized bills including dates of service, name of claimant, type of service from a doctor, dentist, pharmacy or other supplier
• Copies of prescription label that includes price and receipt

Dependent Care Reimbursement Account

• Completed claim form only

Orthodontia Reimbursement Account

• Please submit claims using the Healthcare & Dependent Care Reimbursement Account Claim Form above

How to submit your claim form:

For faster processing, fax the completed FSA/HRA Claim Reimbursement Form and receipts to:

FAX: (866) 635-1329

EMAIL:Flex@gilsbar.com