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ACCOUNT CLAIM FORM
SECTION A – Employee Information (PLEASE PRINT)
SECTION B – Expense Information (PLEASE PRINT)
SECTION C – Provider Information (for Dependent Care only)
For expenses to be eligible this section must be completed and Total expenses incurred for services rendered to the signed by the Provider of dependent care services.
individual(s) on the date(s) specified in Section B.
TAX I.D. NUMBER OR SOCIAL SECURITY NUMBER SECTION D – Employee Signature
I certify that the expenseI certify that the expenses listed above have been incurred by me and/or my eligible dependents and qualify forreimbursement. These expenses have not been reimbursed and are not reimbursable under my major medical plan or any other health plan,such as an individual policy or my spouse’s or dependent’s health plan. I understand that the expense for which I am reimbursed may notbe used to claim any Federal income tax deduction or credit.
RETURN THIS FORM TO:
MEDICAL FLEXIBLE SPENDING ACCOUNT EXPENSES
Medical expenses include payments you make for the diagnosis, treatment or prevention of disease or for treatment affecting any part or function of the body and theamounts you pay for transportation to get medical care.
The following is a partial listing of medical expenses which are allowed and disallowed through your spending account. In general, the medical expenses that are allowable
deductions on your federal income tax form (IRC Section 213(d)) are also reimbursable expenses through your flexible spending account.
ALLOWED EXPENSES
DISALLOWED
Cosmetic surgery (expenses exceptions if medically necessary) Dancing lessons, swimming lessons, etc., even if recommended by your doctor for the general improvement of your health Insurance premiums-for an individual and/or spouses health, dental premiums for life insurance and/or policies covering loss of earnings, loss of a limb Over-the-counter medicines (i.e. aspirin, cough syrup, vitamins, Rogaine) Psychoanalysis received as part of training to be a psychoanalyst Hearing aids & batteriesHospital servicesImmunizationsInsulinInsurance deductibles (health, dental, and vision)Laboratory feesLaser eye surgery HOW TO FILE A CLAIM
Massage therapy with letter stating medical necessityMedical monitoring and testing devices To receive reimbursement for eligible expenses, mail OR fax (not
both) a completed claim form along with IRS-required documen- Nursing services–connected with caring for the patient tation of the expense which must include all of the following: Organ donation/organ transplantationOrthodontic fees Operations (excluding cosmetic surgery operations Prescription eyeglasses, including sunglasses - amount charged for each service/supply or the Psychoanalysis, Psychiatric & Psychological treatment feesSmoking cessation programs *CANCELLED CHECKS DO NOT QUALIFY AS THIRD-PARTY
DOCUMENTATION AND ARE NOT ACCEPTED BY THE IRS.
Transportation–amounts primarily for and essential to medical careVaccines Be sure to provide all information requested on the form.
Weight-loss program and/or drugs prescribed to induce weight loss If the form is incomplete or unsigned, it will be returned.
(when accompanied by letter from doctor)Well-child careWheelchairX-ray fees DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT EXPENSES
Dependent care expenses include payments you make for the care of a child under age 13 and/or a dependent regardless of age who requires care due to an inability to carefor him or herself, to enable you (and, if married, your spouse) to remain gainfully employed.
Those dependents unable to care for themselves must spend at least eight (8) hours a day in your home for the care to be eligible, and you must declare them as a dependent(or have the ability to declare them as a dependent except for their level of gross income) on your federal tax return.
Reimbursement for amounts cannot be claimed if paid to your spouse, anyone you claim as a tax dependent, or your child under age 19. Any expenses reimbursed throughour spending account cannot be claimed for income tax purposes.
ALLOWED EXPENSES
DISALLOWED
Services solely for the purpose of household cleaning After-school programIn-home child and dependent care servicesDay camp expensesElder careAny other qualified dependent care expenses as defined by the IRS

Source: http://www.crookston.org/web/parish/claim_form.pdf