Page 1 of 1 - Welfare-508 (03/2020) Please fax, mail, or email your claim form and receipts to the following: Mail: National Benefit Services, LLC, P.O. Box 6980, West Jordan, UT 84084 Fax: (844) 438-1496 Email: [email protected] (PDF, TIFF, or JPG files only) Flexible Spending Account (FSA) Claim Form Instructions For Quick Claim Processing: Fully complete & sign this claim form Attach copies of supporting EOB, receipts, vouchers, bills, etc. All receipts must include a date, description, and amount of the service Please list one expense per line Please print in dark blue or black ink when using this form Please allow 2 business days for claims to be processed For Account Balance: Go to my.nbsbenefits.com or call (855) 399-3035 1 Personal Information Employee Name Company Name No Yes Street Address, City, State, Zip Address Change? Phone Number Social Security Number 2 Dependent Care Expenses (Dates of Service are required in order to process claim) Date of Service Service Provider Tax ID# or SS# Dependent’s Name Age Amount Start Date End Date 1 2 3 4 Total Dependent Care Expenses 3 Health Care Expenses Date of Service Rx Dental Vision Ortho dontia Other Services: Please Specify Person Receiving Service Amount MM DD YY 1 2 3 4 5 6 7 8 9 Total Health Care Expenses 4 Employee Signature I, the undersigned, attest that to the best of my knowledge these statements are complete and true. I authorize the release of any medical information to my spouse. I certify these expenses are for valid services provided on the dates indicated and will not be reimbursed or claimed under any other Plan or claimed as a tax deduction. Employee Signature Date
National Benefit Services - Flexible Spending Account (FSA ......Mail: National Benefit Services, LLC, P.O. Box 6980, West Jordan, UT 84084 Fax: (844) 438-1496 Email: [email protected]
Jan 31, 2021
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Page 1 of 1 - Welfare-508 (03/2020)
Please fax, mail, or email your claim form and receipts to the following: Mail: National Benefit Services, LLC, P.O. Box 6980, West Jordan, UT 84084
Fax: (844) 438-1496 Email: [email protected] (PDF, TIFF, or JPG files only)
Flexible Spending Account (FSA) Claim Form
Instructions For Quick Claim Processing: Fully complete & sign this claim form Attach copies of supporting EOB, receipts, vouchers, bills, etc. All receipts must include a date, description, and amount of the service Please list one expense per line Please print in dark blue or black ink when using this form Please allow 2 business days for claims to be processed
For Account Balance: Go to my.nbsbenefits.com
or call (855) 399-3035
1 Personal Information
Employee Name Company Name
No Yes Street Address, City, State, Zip Address Change?
Phone Number Social Security Number
2 Dependent Care Expenses (Dates of Service are required in order to process claim) Date of Service
Service Provider Tax ID#
or SS#
Dependent’s Name
Age
Amount
Start Date End Date
1
2
3
4
Total Dependent Care Expenses
3 Health Care Expenses Date of Service
Rx Dental Vision
Orthodontia
Other Services: Please Specify
Person Receiving Service
Amount
MM DD YY
1
2
3
4
5
6
7
8
9
Total Health Care Expenses
4 Employee Signature I, the undersigned, attest that to the best of my knowledge these statements are complete and true. I authorize the release of any medical information to my spouse. I certify these expenses are for valid services provided on the dates indicated and will not be reimbursed or claimed under any other Plan or claimed as a tax deduction.
Employee Signature Date
my.nbsbenefits.comBrookeOTypewritten TextMedical
BrookeOTypewritten TextHospital
Employee Name: Company Name: Street Address City State Zip: Address Change: OffPhone Number: Social Security Number: 1: 2: 3: 4: End Date 1: End Date 2: End Date 3: End Date 4: 1_2: 2_2: 3_2: 4_2: 1_3: 2_3: 3_3: 4_3: 1_4: 2_4: 3_4: 4_4: 1_5: 2_5: 3_5: 4_5: 1_6: 2_6: 3_6: 4_6: 5: 6: 7: 8: 9: 1_7: 2_7: 3_7: 4_7: 5_2: 6_2: 7_2: 8_2: 9_2: 1_8: 2_8: 3_8: 4_8: 5_3: 6_3: 7_3: 8_3: 9_3: 1_9: 2_9: 3_9: 4_9: 5_4: 6_4: 7_4: 8_4: 9_4: Service 1: Service 2: Service 3: Service 4: Service 5: Service 6: Service 7: Service 8: Service 9: 1_10: 2_10: 3_10: 4_10: 5_5: 6_5: 7_5: 8_5: 9_5: Date: Check Box1: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffCheck Box18: OffCheck Box19: OffCheck Box10: OffCheck Box111: OffCheck Box112: OffCheck Box113: OffCheck Box114: OffCheck Box115: OffCheck Box116: OffCheck Box117: OffCheck Box118: OffCheck Box119: OffCheck Box120: OffCheck Box122: OffCheck Box133: OffCheck Box144: OffCheck Box155: OffCheck Box166: OffCheck Box177: OffCheck Box188: OffCheck Box199: OffCheck Box100: OffCheck Box109: OffCheck Box198: OffCheck Box187: OffCheck Box176: OffCheck Box165: OffCheck Box154: OffCheck Box143: OffCheck Box132: OffCheck Box121: OffCheck Box2: OffCheck Box222: OffCheck Box1333: OffCheck Box1444: OffCheck Box1555: OffCheck Box1777: OffCheck Box1888: OffCheck Box1999: OffCheck Box19988: OffCheck Box18877: OffCheck Box17766: OffCheck Box16655: OffCheck Box15544: OffCheck Box14433: OffCheck Box13322: OffTotal Dependent Care Expenses: Total Dependent Care Expenses2:
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