HEALTH CARE SPENDING ACCOUNT 
CLAIM FOR REIMBURSEMENT


Employer Name: 
Employee Name: Social Sec. No. 
Street Address: City: 
State: Zip Code: 
HEALTH CARE EXPENSES 
NAME OF PERSON FOR 
WHOM HEALTH CARE 
SERVICE WAS PROVIDED 
DATES OFSERVICE 
FROM TO 
PROVIDER 
OF SERVICE 
(A) 
TOTAL CHARGE 
(B) 
AMOUNT PAID BY 
OTHER SOURCES 
(A-B) 
AMOUNT TO 
BE REIBURSED 
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 by 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 the 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. 
COMPLETE & RETURN TO: 
FITZHARRIS & COMPANY, INC.

 PO BOX 9182 
FARMINGDALE, N.Y. 11735

 (516) 777-2244 - FAX: (516) 777-5777 / 78