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Reimbursement Claim Form

Request for Reimbursement – Claim Form

After filling out form, please scroll to the bottom and hit Submit.

Scan and email any receipt(s) to darlene@shafferins.com.

    First Name

    M.I.

    Last Name

    Address

    City

    State

    Zip

    Employer Name

    Work Phone Number

    (FSA) Medical Expense(s) to be reimbursed

    Date of Service (MM/DD/YYYY)

    Patient Name

    Relationship

    Name of Provider

    Description of Service

    Claim Amount

    Date of Service (MM/DD/YYYY)

    Patient Name

    Relationship

    Name of Provider

    Description of Service

    Claim Amount

    Date of Service (MM/DD/YYYY)

    Patient Name

    Relationship

    Name of Provider

    Description of Service

    Claim Amount

    Date of Service (MM/DD/YYYY)

    Patient Name

    Relationship

    Name of Provider

    Description of Service

    Claim Amount

    Date of Service (MM/DD/YYYY)

    Patient Name

    Relationship

    Name of Provider

    Description of Service

    Claim Amount

    Total Claim

    Dependent Day Care Claims (Only)

    Service Start (MM/DD/YYYY)

    Service End (MM/DD/YYYY)

    Dependent Name

    Age

    Dependent Care Provider Name

    Dependent Care Provider Address

    Provider Tax ID

    Claim Amount

    Service Start (MM/DD/YYYY)

    Service End (MM/DD/YYYY)

    Dependent Name

    Age

    Dependent Care Provider Name

    Dependent Care Provider Address

    Provider Tax ID

    Claim Amount

    Service Start (MM/DD/YYYY)

    Service End (MM/DD/YYYY)

    Dependent Name

    Age

    Dependent Care Provider Name

    Dependent Care Provider Address

    Provider Tax ID

    Claim Amount

    Service Start (MM/DD/YYYY)

    Service End (MM/DD/YYYY)

    Dependent Name

    Age

    Dependent Care Provider Name

    Dependent Care Provider Address

    Provider Tax ID

    Claim Amount

    Service Start (MM/DD/YYYY)

    Service End (MM/DD/YYYY)

    Dependent Name

    Age

    Dependent Care Provider Name

    Dependent Care Provider Address

    Provider Tax ID

    Claim Amount

    Total Claim

    EMPLOYEE'S CERTIFICATION FOR EMPLOYMENT
    I certify that the expenses for reimbursemet requested from my accounts were incurred by me (and/or my spouse and/or eligible dependents), were not reimbursed by any other plan, and, to the best of my knowledge and belief, are eligible for reimbursement under my Reimbursement Plans. I (or we) will not use the expense reimbursed through this account as deductions or credits when filing my (our) individual income tax return.
    Any person who knowingly and with intent to injure, defraud, or decieve any insurance company, administrator, or plan service provider, files a statement of claim containing false, incomplete, or misleading information may be guilty of a criminal act punishable under law.