UnitedHealthcare CLAIM SUBMISSION / WITHDRAWAL REQUEST FORM FSA Claim Form.pdf · MAIL CLAIM FORM TO: page 1

UnitedHealthcare CLAIM SUBMISSION / WITHDRAWAL REQUEST FORM FSA Claim Form.pdf · MAIL CLAIM FORM TO:

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Text of UnitedHealthcare CLAIM SUBMISSION / WITHDRAWAL REQUEST FORM FSA Claim Form.pdf · MAIL CLAIM FORM...

  • MAIL CLAIM FORM TO:Health Care Account Service Center PO Box 981506 El Paso, TX 79998-1506 Fax: 915-231-1709 Toll Free Fax: 866-262-6354 Customer Service: 800-331-0480

    UnitedHealthcareCLAIM SUBMISSION / WITHDRAWAL REQUEST FORM

    Hanford Employee Welfare Trust (HEWT) FSA Group Number 702637

    A-6003-579# (REV 3)

    Day Care Provider's Certification of Services Rendered (Please Print)I, the signer below, certify that the services listed in Part 3 above, were rendered by me and charges incurred have been paid for.

    Member ID

    Employer NameMailing Address, City, State, Zip Code

    Please notify your benefits administrator of any address changes.

    Please Check One Box For Each Expense Type: MD=Medical, RX=Prescription, OTC=Over-the-Counter, VIS=Vision, DN=Dental, HR=Hearing.

    Dependent/Child's Name

    Daytime Telephone No.

    Type of Dependent/Child Care Service

    Date of Birth

    Certification For Reimbursement

    Employee Name (Last and First)

    Date of Birth mm/dd/yyyy

    Dependent/Child Care Expenses Subtotal

    Total Request for Reimbursement

    Date(s) of Service mm/dd/yyyy

    $

    From: To:

    To:

    I certify that any expenses for which I am requesting reimbursement from my Health Care/Dependent Care FSA, as itemized above, were incurred by me (and/or my spouse and/or eligible dependents) for medical care as permitted under the Health Care/Dependent Care FSA, and have not been reimbursed and I will not seek reimbursement under any other plan. I understand that expenses reimbursed through the FSA program cannot be used to claim any federal income tax deduction or credit. To the best of my knowledge and belief, my statements are complete and true.

    From:

    DATE:

    From:

    Day Care Provider's Tax ID #:

    Amount

    Provider Tax ID # (optional)

    Provider Phone #

    Date of Birth

    Provider Address

    Description of Service

    To:

    From:

    Name of Provider

    Patient Name / Relationship

    MDType of service (Please check)

    Date of Service

    Date of Service

    RX OTC VIS DN HR

    Request Amount

    HRDNVISOTCRX

    Date of Service

    Date of Service

    Type of service (Please check)MD

    Patient Name / Relationship

    Name of Provider

    From:

    To:

    To:

    EMPLOYEE SIGNATURE:

    To:From:

    Part 2 Health Care Expenses (Please Print) Itemize each expense using separate entries below. Use additional forms as necessary.

    Part 1 Employee Information (Please Print) Please read the instructions in their entirety before completing form.

    Part 3 Dependent Care Expenses (Please Print) Itemize each expense using a separate line. Use additional forms as necessary.

    Day Care Provider and Company Name: Day Care Provider's Address:

    Day Care Provider's Signature and Title:

    Description of Service

    Provider Address

    Date of Birth

    Provider Phone #

    Provider Tax ID # (optional)

    Amount

    Relationship

    OFFICIAL USE ONLY WHEN FILLED IN

    MAIL CLAIM FORM TO:

    Health Care Account Service CenterPO Box 981506El Paso, TX 79998-1506Fax: 915-231-1709 Toll Free Fax: 866-262-6354

    Customer Service: 800-331-0480

    UnitedHealthcare

    CLAIM SUBMISSION / WITHDRAWAL REQUEST FORM

    Hanford Employee Welfare Trust (HEWT)

    FSA Group Number 702637

    A-6003-579# (REV 3)

    Day Care Provider's Certification of Services Rendered (Please Print)

    I, the signer below, certify that the services listed in Part 3 above, were rendered by me and charges incurred have been paid for.

    Member ID

    Employer Name

    Mailing Address, City, State, Zip Code

    Please notify your benefits administrator of any address changes.

    Please Check One Box For Each Expense Type: MD=Medical, RX=Prescription, OTC=Over-the-Counter, VIS=Vision, DN=Dental, HR=Hearing.

    Dependent/Child's Name

    Daytime Telephone No.

    Type of Dependent/Child Care Service

    Date of Birth

    Certification For Reimbursement

    Employee Name (Last and First)

    Date of Birth

    mm/dd/yyyy

    Dependent/Child Care Expenses Subtotal

    Total Request for Reimbursement

    Date(s) of Service mm/dd/yyyy

    $

    From:

    To:

    To:

    I certify that any expenses for which I am requesting reimbursement from my Health Care/Dependent Care FSA, as itemized above, were incurred by me (and/or my spouse and/or eligible dependents) for medical care as permitted under the Health Care/Dependent Care FSA, and have not been reimbursed and I will not seek reimbursement under any other plan. I understand that expenses reimbursed through the FSA program cannot be used to claim any federal income tax deduction or credit. To the best of my knowledge and belief, my statements are complete and true.

    From:

    DATE:

    From:

    Day Care Provider's Tax ID #:

    Amount

    Provider Tax ID # (optional)

    Provider Phone #

    Date of Birth

    Provider Address

    Description of Service

    To:

    From:

    Name of Provider

    Patient Name / Relationship

    MD

    Type of service (Please check)

    Date of Service

    Date of Service

    RX

    OTC

    VIS

    DN

    HR

    Request Amount

    HR

    DN

    VIS

    OTC

    RX

    Date of Service

    Date of Service

    Type of service (Please check)

    MD

    Patient Name / Relationship

    Name of Provider

    From:

    To:

    To:

    EMPLOYEE SIGNATURE:

    To:

    From:

    Part 2 Health Care Expenses (Please Print) Itemize each expense using separate entries below. Use additional forms as necessary.

    Part 1 Employee Information (Please Print) Please read the instructions in their entirety before completing form.

    Part 3 Dependent Care Expenses (Please Print) Itemize each expense using a separate line. Use additional forms as necessary.

    Day Care Provider and Company Name:

    Day Care Provider's Address:

    Day Care Provider's Signature and Title:

    Description of Service

    Provider Address

    Date of Birth

    Provider Phone #

    Provider Tax ID # (optional)

    Amount

    Relationship

    OFFICIAL USE ONLY WHEN FILLED IN

    N:\forms\f3048-A-6003-579.xft

    Jayne Robbins

    03/01/11

    1.0

    FH Benefits

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    FormClient

    Spelling Checker;{224F7DEA-B7C1-11D3-AB40-00902712A5C9};PLSSpeller.cab

    UnitedHealthcare - HEWT Flexible Spending Account Claim Form (see I291)

    nlb

    A-6003-579 (01/03)

    Beth Brown

    MSA

    UnitedHealthcare - Claim Submission/Withdrawal Request HEWT (see I291)

    nlb

    A-6003-579 (REV 3)

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