| Participant Name |
|
ROBERT |
|
Claim Number |
|
521803732 |
| Employer |
|
So_ny |
|
Date Submitted |
|
08-06-2005 |
|
|
| To have your
claim processed: |
|
| 1. |
Print this
page. |
|
| 2. |
Sign and date this
printed page. |
|
| 3. |
Fax or mail this page
with the receipts
or other documentation by 09-05-2005 to:
|
|
| |
Fax Number
1-888-211-9900
(If faxing, don't include a cover letter and
place the printed page before your receipts.)
|
Mailing Address
Y.S.A.
box 785040
Orlando, FL 32878-5040
| |
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|
|
Once your documentation has been received, your claim
will be processed within 10 days. Your claim will be denied if receipts or
other documentation aren't received within 30 days.
Health Care Items
| |
Date
of Service |
Patient |
|
Service
Provider |
|
Type of Service |
Requested
Amount |
|
| 1. |
07-30-2005 |
Robert |
|
Long's Drugs |
|
Prescription |
$35.00 |
|
| 2. |
07-30-2005 |
Noelle |
|
Long's Drugs |
|
Prescription |
$35.00 |
|
|
| |
|
|
|
|
|
Claim Total |
$70.00 |
|
Employee Certification
I hereby certify that the above information is correct and that
the expenses for which I've requested reimbursement, or for which I'm
validating:
- Were incurred for services or supplies received by my eligible
dependents or me under the plan
- Were for services or supplies furnished on or after the date my
spending account takes effect
- Haven't been previously reimbursed in any other way or from any
other source and won't be submitted for future reimbursement
- Don't include any amounts that are otherwise payable by plans for
which my dependents or I are eligible
I understand that health care reimbursements aren't
eligible deductions on my individual tax return. Claim decisions will be
made according to plan provisions. So_ny and Hewitt Associates aren't
liable for any penalties or damages as a result of any inappropriate debit
card use.
|
|
| Employee Signature |
|
SSN (optional) |
|
Date
| | 
