HEALTH CARE SPENDING ACCOUNT
Claim For Reimbursement


Name of Employer 
Employee Name Soc. Sec. Number 
--
Employee Address Street City 
State Zip 

HEALTH CARE EXPENSES 

NAME OF PERSON FOR WHOM 
HEALTH CARE SERVICE WAS PROVIDED 
DATES OF 
SERVICE 
PROVIDER OF 
SERVICE 
(A) 
TOTAL 
CHARGE 
(B) 
AMOUNT PAID BY 
OTHER SOURCES 
(A-B) 
AMOUNT TO BE 
REIMBURSEDFrom To 
TOTALS 

CERTIFICATION
I certify that the expenses for which I am requesting reimbursement meet all of the conditions listed below:
-They were incurred for services or supplies received by me or my eligible dependents under the plan.
-They were for services or supplies furnished while I was a participant in the Plan.
-I have not been reimbursed for these expenses and they are not reimbursable from any other health plan.


I understand that reimbursement of these expenses can be requested and made only after I have collected all 
benefit payments available from all plans under which my eligible dependents and I are covered.


I further certify that I have not deducted nor will deduct on my individual income tax return any of the 
expenses reimbursed through my Health Care Spending Account


I understand that reimbursement Will be made in accordance with the provisions of the plan in which I 
participate. I accept responsibility for the proper treatment of benefits paid under this plan with respect to 
eligibility, income tax reporting and liability. 

EMPLOYEE SIGNATURE DATE 
COMPLETION OF CLAIM FORM 

• Complete all information on the claim form for each amount claimed for reimbursement. 
-

Make sure the claim does not include items for more than one plan year. 

-

You must sign and date claim form. 

• A copy of a bill or other written statement from the provider of service is acceptable only 
when NO other insurance is applicable. 
-

If Insurance Is applicable, a statement from all medical/dental Insurance carriers showing 
deductible and copayments is required. 

MAIL COMPLETED FORM TO:
FITZHARRIS & COMPANY, INC.
P0 BOX 9182
FARMINGDALE. NY 11735-9182


(516) 777-2244 1-800-321-1336 
FAX (516) 777-5777/78