New York State's Flexible = Spending Accounts - HCSA Reimbursement Request Form

From: Subject: New York State's Flexible Spending Accounts - HCSA Reimbursement Request Form Date: Thu, 19 Apr 2007 10:26:50 -0400 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01C7826D.3DFDD540" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.3028 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01C7826D.3DFDD540 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.flexspend.state.ny.us/2007/forms/hcsa_reimb_form.html New York State's Flexible = Spending Accounts - HCSA Reimbursement Request Form

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HEALTH CARE SPENDING=20 ACCOUNT
REIMBURSEMENT REQUEST=20 FORM

Plan=20 = Year: __________

SECTION A

Enrollee Name	Street Address
Social Security Number	Daytime Phone	City	State	Zip

SECTION B

SUMMARY OF HEALTH CARE = SPENDING=20 ACCOUNT EXPENSES	DATES SERVICE=20 PROVIDED
Name of Person Receiving = Services	Relationship to Enrollee	Name and Address of Provider of=20 Services (ex.: hospital, doctor, dentist, = pharmacy,=20 medical supply store)	From MO/DAY/YR	To MO/DAY/YR	Amount to be Reimbursed

I understand, agree and = certify to=20 the following:

TOTAL AMOUNT = $_____________

I will use my HCSAccount only to pay for=20 IRS-qualified expenses, permitted under the = HCSAccount=20 plan, that are provided to me, my spouse and my=20 IRS-eligible dependents, on the date(s) = indicated above=20 as being incurred within my period of coverage = during=20 the Plan Year.=20

I will request reimbursement only after the = health=20 care services have been provided.=20

I have not and will not seek reimbursement = through=20 any other source, and will exhaust all other = sources of=20 reimbursement before seeking reimbursement from = my=20 HCSAccount.=20

I will collect and maintain sufficient = documentation=20 to validate my reimbursed HCSAccount expenses.=20

I will not claim any reimbursed HCSAccount = expense=20 for any federal income tax deduction or credit.=20

I specifically release New York State and = FBMC from=20 any liability resulting from either my = participation in=20 the HCSAccount or any misrepresentation I make = regarding=20 my requests for reimbursement.=20

I have read and understand the information = contained=20 on the front and back of this form. =

Enrollee = Signature:

Date:

REV.=20 08/05

NEW=20 YORK STATE FLEX SPENDING = ACCOUNT
A STATE=20 EMPLOYEE BENEFIT THAT PUTS MONEY IN YOUR = POCKET

FOR OFFICE USE ONLY

Date

Authorization=20 #

Initial

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Return =

HEALTH CARE SPENDING = ACCOUNT
INSTRUCTIONS FOR=20 REIMBURSEMENT

General=20 Instructions:

		Make sure you complete Section B in its = entirety.
		Reimbursement cannot be claimed if the cost has been = or=20 can be reimbursed under any other source.
		Services must have been incurred to receive = reimbursement.=20 You may not request reimbursement until you have = received the=20 service, regardless of when you pay for it.
		The expenses for which you receive reimbursement = cannot be=20 claimed on your income tax return.
		According to IRS regulation, any unused year-end = balance=20 in your spending account may not be carried over to = the next=20 Plan Year. It will be forfeited to New York State, as = your=20 employer.
		Be sure to sign and date this form, after reading it = carefully. Mail or fax the completed form to FBMC and = keep a=20 copy for your records.
		You may access your account information or request=20 reimbursement request forms 24 hours each day by = calling=20 FBMC's toll-free Interactive Benefits Information Line = at=20 1-800-865-3262.
		The standard mileage rate reimbursable for use of an = automobile to obtain medical care is subject to change = by the=20 IRS annually. Visit the Flex Spending Account website = at=20 www.flexspend.state.ny.us for the current rate. Your = request=20 for mileage reimbursement must include documentation = (such as=20 a receipt from a doctor=92s office) to verify that the = travel is=20 related to medically necessary=20 treatment.

Documentation = Instructions:

		To request health care expense reimbursement, a copy = of=20 your statement, bill or receipt from your health care = service=20 provider(s) showing the services received must be = attached to=20 this form. This statement must clearly identify the = patient=92s=20 name, service provider=92s name and address, date and = type of=20 service provided, and amount of expense. For = reimbursement of=20 prescription drug costs, your receipt must also = include the=20 prescription name and number.
		At the beginning of the Plan Year in which you seek=20 reimbursement for orthodontia expenses, you must = submit a copy=20 of the service contract between you and the = orthodontist=20 describing the payment arrangement/schedule. = Orthodontic=20 procedures for primarily cosmetic reasons are = ineligible for=20 reimbursement.
		Copies of cancelled checks or charge card receipts = are not=20 sufficient documentation of incurred = expenses.
		Submit legible photocopies of your original = statements,=20 bills or receipts, and retain the originals for your=20 records.
		Expenses for cosmetic services and procedures, and = items=20 that have a personal, living or family use, are = ineligible for=20 reimbursement through the HCSAccount. The health care = services=20 must promote the proper function of the body or must = be=20 designed to treat, prevent, cure or mitigate a = specific=20 medical condition as defined by IRS regulations. A = letter from=20 your health care provider indicating the services are=20 medically necessary must be submitted with the request = for=20 reimbursement of services that are generally = considered=20 cosmetic, personal, living or family in=20 nature.

Period of=20 Coverage:

		Reimbursement can only be made for expenses = resulting from=20 medically necessary services that have been provided = within=20 your period of coverage. Your period of coverage is = January 1=20 through December 31 if you enroll during the open = enrollment=20 period. If you enroll during the Plan Year as a new = hire, your=20 period of coverage begins on the 61st consecutive = calendar day=20 of your employment. If you enroll during the Plan Year = due to=20 a change in status, your period of coverage will be = based on=20 the date your CIS request is received by the Plan. If = you=20 terminate employment or take an unpaid leave of = absence during=20 the Plan Year, your period of coverage will end once = you leave=20 the payroll and stop contributing to your = account.
		If a service is provided during your current period = of=20 coverage and will continue to be provided in a = subsequent Plan=20 Year, you will not receive reimbursement for the = services you=20 receive in that subsequent Plan Year unless you = re-enroll in=20 the HCSAccount and submit a reimbursement request form = for=20 that period of coverage. A new letter from your health = care=20 provider indicating the services are medically = necessary must=20 be submitted with the request for reimbursement in the = subsequent Plan Year.
		If dates of service begin in one Plan Year and end = in the=20 next Plan Year, and you are enrolled for both years, = please=20 prorate the expenses and complete a separate form for = each=20 Plan Year.
		New York State has allowed for a 90-day grace period = after=20 the end of your Plan Year during which you may submit=20 reimbursement requests for services that occurred = during your=20 period of coverage. Refer to your enrollment book for = detailed=20 information.

MAIL = FORM=20 TO:
Fringe Benefits Management Company
Post = Office Box=20 1820
Tallahassee, Florida 32302-1820
Customer = Service:=20 (800) 342-8017

OR...

FAX FORM TO: (800)=20 743-3271

If you=20 fax your reimbursement request form to FBMC, do not = mail the=20 form as well.=20 =