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Transit )Tj /TT0 1 Tf 5 0 0 5 65.731 450.6719 Tm ( )Tj /T1_0 1 Tf 5.5 0 0 5.5 39.3325 614.8398 Tm (MFSA HRA)Tj 0.004 0.004 0.004 rg /T1_1 1 Tf 9 0 0 9 226.0181 22.3447 Tm [( )2( )2( )]TJ 0.929 0.11 0.141 rg 0.788 0.55 Td [( Email )1(C)1(laim to: )]TJ 0.137 0.122 0.125 rg 14.014 -0.074 Td [(claims@fle)-1(x125.com)]TJ ET q 0 0 612 792 re W n q 1 0 0 1 495.7324 631.2173 cm 0.004 0.004 0.004 RG 0 0 m 0 -58.717 l S Q 0.067 0 0 RG 32.207 572.5 544.126 58.432 re S q 1 0 0 1 84.4868 598 cm 0.004 0.004 0.004 RG 0 0 m 491.025 0 l S Q q 1 0 0 1 84.4868 585.4321 cm 0.004 0.004 0.004 RG 0 0 m 491.025 0 l S Q 1 w 32.207 484.5 544.126 74.783 re S q 1 0 0 1 31.874 536 cm 0 0 m 544.903 0.5 l S Q q 1 0 0 1 122.5 559.2832 cm 0 0 m 0 -74.783 l S Q q 1 0 0 1 240.1606 559.2832 cm 0 0 m 0 -48.783 l S Q q 1 0 0 1 203.4092 536.5 cm 0 0 m 0 -26 l S Q q 1 0 0 1 325.999 559.2832 cm 0 0 m 0 -48.783 l S Q q 1 0 0 1 401.417 559.2832 cm 0 0 m 0 -48.783 l S Q q 1 0 0 1 495.7324 559.2832 cm 0 0 m 0 -48.783 l S Q q 1 0 0 1 31.7188 524 cm 0 0 m 543.793 0 l S Q q 1 0 0 1 32.207 510.5 cm 0 0 m 543.305 0 l S Q 32.264 404.833 544.125 66.354 re S q 1 0 0 1 575.5117 445.1777 cm 0 0 m -543.249 0 l 0 0 l h S Q q 1 0 0 1 94 432.833 cm 0 0 m 481.512 -0.5 l S Q q 1 0 0 1 94 418.333 cm 0 0 m 482.777 0 l S Q q 1 0 0 1 32.2627 404.833 cm 0 0 m 544.515 0 l S Q q 1 0 0 1 94 471.1875 cm 0 0 m 0 -66.354 l S Q q 1 0 0 1 131.5 445.1777 cm 0 0 m 0 -40.345 l S Q q 1 0 0 1 175 471.1875 cm 0 0 m 0 -66.354 l S Q q 1 0 0 1 303.6152 471.1875 cm 0 0 m 0 -66.354 l S Q q 1 0 0 1 495.7324 471.1875 cm 0 0 m 0 -66.354 l S Q q 1 0 0 1 52.9541 16.3447 cm 0.067 0 0 rg 0 0 m 511.51 0 l h f Q q 1 0 0 1 36.9541 16.3447 cm 0.5 w 0 0 m 527.513 0 l S Q q 1 0 0 1 461.333 69.501 cm 0.004 0.004 0.004 RG 0.75 w 0 0 m 102.634 0 l S Q q 1 0 0 1 127.333 709.1665 cm 0.067 0 0 rg 0 0 m 256.667 0 l h f Q q 1 0 0 1 127.3325 709.1665 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 127.3325 695.1665 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 127.333 680.5 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 127.3325 666.5 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 134.999 572.501 cm 0 0 0 rg 0 0 m 0 58.432 l h f Q q 1 0 0 1 134.9995 630.9321 cm 0 0 0 RG 0 0 m 0 -58.432 l S Q Q BT 0 0 0 rg /T1_0 1 Tf 7 0 0 7 137.4346 622.5996 Tm ( Name of Person )Tj 0 -1.114 TD (Receiving Medical Service)Tj ET q 0 0 612 792 re W n q 1 0 0 1 169.167 559.2832 cm 0.067 0 0 RG 1 w 0 0 m 0 -48.783 l S Q Q BT /T1_0 1 Tf 7 0 0 7 34.6665 375.0342 Tm (Please read carefully and be sure your claim is completed in its entiret\ y to ensure ther)Tj 0 -1.2 TD (or any documents included as backup as this may cause a delay in process\ ing your claim. )Tj 39.141 1.2 Td [(e)-1( is no de)1(lay in processing. Please do not use a highlighter on claim form, receip\ ts,)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 358.0342 Tm (1\) Complete all applicable sections, sign and date. Services must be in\ curred in order to be reimbursed.)Tj 0 -1.231 TD (2\) Attach all required documentation )Tj /T1_0 1 Tf (\(New in 2011: For an OTC medicine, please include a copy of your medica\ l provider\222s prescription or a pharmacy receipt showing )Tj (the prescription #\))Tj /T1_3 1 Tf 83.754 0 Td (. )Tj -83.754 -1.231 Td (3\) Mail, fax or email the completed claim form \(scanned with signature\ if necessary\) to AmeriFlex.)Tj T* (4\) Please allow 2-3 weeks for paper check delivery or 7-10 days for dir\ ect deposits from the processing date.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 320.0342 Tm (MFSA/HRA Expenses - Acceptable forms of documentation include:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 312.0342 Tm [(1\) Explanation of Benefits \(EOB\): Y)109(our insurance carrier sends you an EOB each time a claim is filed. An EO\ B indicates your personal obligation via co)-19(-insurance or a deductible.)]TJ 0.001 -1.231 Td [(2\) R)17(eceipts: Include name of person treated; date expense was incurred; type\ of service; provider name; and amount of expense. \(IRS)( does not allow credit card receipts\))]TJ T* ( )Tj 0 -1.692 TD [(If you participate in both an MFSA and an HRA, funds will be deducted fr\ om each account based on your employer)-42(\222s plan design. If you are responsible for all or a portion of the in\ surance deductible )]TJ 0 -1.231 TD [(before employer HRA funds can be made available, you must submit an HRA \ Activation F)35(orm with an EOB to AmeriFlex once your portion is met as proof of the de\ ductible status. Once approved, the )]TJ T* (employer funded HRA will be activated.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 254.0342 Tm (Orthodontia Expenses:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 246.0342 Tm [(Y)109(our plan may reimburse advanced expenses for orthodontia made through a \ payment plan. Please contact your employer to see if th)(ese \223up)-17(-front)-27(\224 orthodontia expenses apply)86(. Orthodontia expenses)]TJ 74.056 0 Td ( )Tj -74.057 -1.231 Td [(require that both of the following be submitted with the intial claim: \(\ 1\) proof of payment \(e.g)17(. cancelled check, provider bill indicating payments or credit card rece\ ipt\); and \(2\) a copy of the )]TJ T* (orthodontia contract, including amount, down payment, monthly fees and e\ stimated length of treatment.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 215.0342 Tm [(Dependent Day Care Expenses \(R)17(eimbursed only after service is provided\) - Acceptable forms of documen\ tation include:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 207.0342 Tm [(R)17(eceipts including the name of the person for whom the service was provid\ ed, date expense was incurred, type of service, name of)( provider)100(, amount charged and the provider)-43(\222s tax ID number/SSN)45(. )]TJ T* (If you are using a private provider \(i.e. babysitter\) the receipt must\ also include their full name, signature, address and SSN)Tj ( \(IRS does not allow credit card receipts or statements as eligible pro\ of of )Tj T* (expense\). If you have recurring dependent day care expenses, you can ge\ t recurring reimbursement without having to file a claim)Tj ( after each date of service. To set up a recurring claim, you must provi\ de)Tj 0 -1.2 TD (the date range of services that will be provided and a note/statement fr\ om your provider outlining the schedule of expenses for)Tj ( the entire period of the recurring claim. Your first expense must be )Tj T* (substantiated after the service has been provided before you can set up \ a recurring claim. )Tj /T1_0 1 Tf 7 0 0 7 34.6665 162.5342 Tm [(Commuter/T)81(ransportation Expenses:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 153.5342 Tm (The IRS does not permit reimbursement for expenses older than 180 days f\ rom the date incurred.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 138.5342 Tm [(T)100(o avoid delays in reimbursement, please sign and date this claim form an\ d provide notice of any name or address change)1( to AmeriFlex.)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 130.5342 Tm [(I authorize my account\(s\) to be reduced by the amount requested. T)118(o the best of my knowledge and belief)35(, the statements on this form are complete and true. I am claiming reimb\ ursement only for )]TJ 0 -1.231 TD [(eligible expenses incurred by eligible plan participants during the appl\ icable plan year)99(. I certify that these expenses have not previously been reimbursed by t\ his or any other benefit plan, will not be )]TJ T* (reimbursed from any other source and will not be claimed as an income ta\ x deduction. I also understand that I may be asked to )Tj (provide further details \(i.e. a letter of medical necessity from a medi\ cal )Tj T* (practitioner certifying that the expense is to treat or cure a medical c\ ondition or a more detailed certification from me\). I u)Tj [(nderstand that if my claim is for expenses incurred during a Grace P)53(eriod: \(1\) )]TJ T* [(the expenses will be reimbursed first from available amounts remaining a\ t the end of the preceding Plan Y)109(ear and then during the Current Plan Y)108(ear; \(2\) claims are paid in the order in which they are )]TJ T* [(approved; and \(3\) once paid, a claim will not be reprocessed or otherw\ ise re)-17(-)-19(characterized so as to change the Plan Y)109(ear from which funds are taken to pay it.)]TJ /T1_0 1 Tf 11 0 0 11 34.6665 386.8701 Tm (Instructions )Tj ET EMC endstream endobj 831 0 obj <> endobj 832 0 obj <> endobj 833 0 obj <> endobj 834 0 obj <>stream HU XSWK&//PܦԱ(u-Y **TԪg[F}h>ʴ.uo?mτ[v(@u;sνRH0zԸ(Ǽff113ܖ( pRX{80[^aFV-bd3+{kXX|}.O{*C.(߽w,2+7E(~auE 89'ސ__#, 6 o LIdpmfZGڏtEƹJ98Nʼ+\K#|3';D{Hr+ai?\qLs Ni mF6r&%RKW7wώ^>r_N]J#ghXxעzۯ^~c3hpl6~ao=|Qnj0~;I'M2uZSRg32gfef.ST\2y.\|IERcU+jVZޚjo?n-[iv'{~:|G5 ?qWϜ=wů~w5\7-&He*ƴU;V Nq9d(l\KGI'KIW?`^kH7ql_o2\IRjSk;TIQSBT**MͩJ' ^݄00@J2RV pD8.. ׄۚ`M&ElBc+N2W2`d1ҩҚQm 9`0IY1W1HV:`0AP'lgp1D3Hd6f |m(Zu--ggLvLKqSgK]͍U@v{E8qCA(sy-syy9bV;أLMML'륦3MLMLQHS)Lv񜎶+loJ^}Ϋb v&Ȟ\Xne(6b-b #la1V!a֡$h;w،q #5HY+Ey\=73+.[#Df"YAr1 !QB(B 1.``>{ C4Ƒș\ -@i:+Q"%DDi yRGJOqn>8E$0}|mXEðh8\9rF!#&@ ;vdޒe̿%vWv}x_&{XG'i]@r05 1 2~[3va lmNI Ye#;gYt3*YA}=od`rQ,G [^==\;8;ɤF"694PT&(*E*޽۽_z "|xul=s=o+¾ Gڂjm"^ ±n40Ի1ՍiPOɡpz.aO Zd1ULQDZLlF~Nc]>ѿ0=9=̎N'd=/۰,VꓳۯϿkʆчZ;<|(1jX7&YOJJR j%ffTa 59ӾfξOm&oJs_WoPS?/y/?@ ,*G3"%`"`d"q\vBtӮKcWm~a/v?ڵ_:qwn"uۭӏsss~ޘӞWz]^wsjDyT-4It@*jZ4V๹<[O[ZJRԠަ'k)J)V*'IA/Z%|7ߧ-ig'V\U-xK=XKpůnlnO_G;&0o "ޚ8[ѣ7wk*2Kɏ=J\x*֪iHk0N5FLeԀ[ U#t} s;XTYU;>:'&-4vZ˰~^@?}WS+x9QZ16 5_G u*B-FLG'ȱܡ_%χ_ +$yQB8h+V`rU 1Fi,,-1$㸊rΐ ?`)P {li/2VxB1Czefz[Q1~#mc8\'}*(F-b lHt\@x5EUyXVFW47 Yd rs 姴ZU/CN[{8;Hz &% ᜯyzj.xOU =2C3wM8w;)k]XGӸz|ؗ'aW%!_嘁\qyE|dJs~ uC?(4cp.|fģى:~|9'pY' K4n YȢ s_d1|8-e3

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Please do not use a highlighter on claim form, receip\ ts,)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 358.0342 Tm (1\) Complete all applicable sections, sign and date. Services must be in\ curred in order to be reimbursed.)Tj 0 -1.231 TD (2\) Attach all required documentation )Tj /T1_0 1 Tf (\(New in 2011: For an OTC medicine, please include a copy of your medica\ l provider\222s prescription or a pharmacy receipt showing )Tj (the prescription #\))Tj /T1_3 1 Tf 83.754 0 Td (. )Tj -83.754 -1.231 Td (3\) Mail, fax or email the completed claim form \(scanned with signature\ if necessary\) to AmeriFlex.)Tj T* (4\) Please allow 2-3 weeks for paper check delivery or 7-10 days for dir\ ect deposits from the processing date.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 320.0342 Tm (MFSA/HRA Expenses - Acceptable forms of documentation include:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 312.0342 Tm [(1\) Explanation of Benefits \(EOB\): Y)109(our insurance carrier sends you an EOB each time a claim is filed. An EO\ B indicates your personal obligation via co)-19(-insurance or a deductible.)]TJ 0.001 -1.231 Td [(2\) R)17(eceipts: Include name of person treated; date expense was incurred; type\ of service; provider name; and amount of expense. \(IRS)( does not allow credit card receipts\))]TJ T* ( )Tj 0 -1.692 TD [(If you participate in both an MFSA and an HRA, funds will be deducted fr\ om each account based on your employer)-42(\222s plan design. If you are responsible for all or a portion of the in\ surance deductible )]TJ 0 -1.231 TD [(before employer HRA funds can be made available, you must submit an HRA \ Activation F)35(orm with an EOB to AmeriFlex once your portion is met as proof of the de\ ductible status. Once approved, the )]TJ T* (employer funded HRA will be activated.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 254.0342 Tm (Orthodontia Expenses:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 246.0342 Tm [(Y)109(our plan may reimburse advanced expenses for orthodontia made through a \ payment plan. 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Your first expense must be )Tj T* (substantiated after the service has been provided before you can set up \ a recurring claim. )Tj /T1_0 1 Tf 7 0 0 7 34.6665 162.5342 Tm [(Commuter/T)81(ransportation Expenses:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 153.5342 Tm (The IRS does not permit reimbursement for expenses older than 180 days f\ rom the date incurred.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 138.5342 Tm [(T)100(o avoid delays in reimbursement, please sign and date this claim form an\ d provide notice of any name or address change)1( to AmeriFlex.)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 130.5342 Tm [(I authorize my account\(s\) to be reduced by the amount requested. T)118(o the best of my knowledge and belief)35(, the statements on this form are complete and true. I am claiming reimb\ ursement only for )]TJ 0 -1.231 TD [(eligible expenses incurred by eligible plan participants during the appl\ icable plan year)99(. I certify that these expenses have not previously been reimbursed by t\ his or any other benefit plan, will not be )]TJ T* (reimbursed from any other source and will not be claimed as an income ta\ x deduction. I also understand that I may be asked to )Tj (provide further details \(i.e. a letter of medical necessity from a medi\ cal )Tj T* (practitioner certifying that the expense is to treat or cure a medical c\ ondition or a more detailed certification from me\). I u)Tj [(nderstand that if my claim is for expenses incurred during a Grace P)53(eriod: \(1\) )]TJ T* [(the expenses will be reimbursed first from available amounts remaining a\ t the end of the preceding Plan Y)109(ear and then during the Current Plan Y)108(ear; \(2\) claims are paid in the order in which they are )]TJ T* [(approved; and \(3\) once paid, a claim will not be reprocessed or otherw\ ise re)-17(-)-19(characterized so as to change the Plan Y)109(ear from which funds are taken to pay it.)]TJ /T1_0 1 Tf 11 0 0 11 34.6665 386.8701 Tm (Instructions )Tj ET EMC Q endstream endobj 846 0 obj <> endobj 851 0 obj <> endobj 852 0 obj <> endobj 853 0 obj <> endobj 854 0 obj <> endobj 855 0 obj <> endobj 856 0 obj <> endobj 857 0 obj <>stream HWn}/T!~K8EtVG(Y8E/kSޝd$qｊ9-*Fp\pWc4 uѡ'ã,4/x="bF4[k_k'y3XdqWkk-L:ey7cv.Jv:.F./'=v>9ޕw5e;烳ŠQ+°=c,洡눭ו氭.>륱"M޳<ӞKJy2K6x~(is<.aIlNvV,fi@u2|^ˣ6g~2H8~aZ*n(EJrmZj>1>[ۨIF% B &ͺ2 GŴ># -qh챫o|R {\o ~i')$r 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Please do not use a highlighter on claim form, receip\ ts,)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 358.0342 Tm (1\) Complete all applicable sections, sign and date. Services must be in\ curred in order to be reimbursed.)Tj 0 -1.231 TD (2\) Attach all required documentation )Tj /T1_0 1 Tf (\(New in 2011: For an OTC medicine, please include a copy of your medica\ l provider\222s prescription or a pharmacy receipt showing )Tj (the prescription #\))Tj /T1_3 1 Tf 83.754 0 Td (. )Tj -83.754 -1.231 Td (3\) Mail, fax or email the completed claim form \(scanned with signature\ if necessary\) to AmeriFlex.)Tj T* (4\) Please allow 2-3 weeks for paper check delivery or 7-10 days for dir\ ect deposits from the processing date.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 320.0342 Tm (MFSA/HRA Expenses - Acceptable forms of documentation include:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 312.0342 Tm [(1\) Explanation of Benefits \(EOB\): Y)109(our insurance carrier sends you an EOB each time a claim is filed. An EO\ B indicates your personal obligation via co)-19(-insurance or a deductible.)]TJ 0.001 -1.231 Td [(2\) R)17(eceipts: Include name of person treated; date expense was incurred; type\ of service; provider name; and amount of expense. \(IRS)( does not allow credit card receipts\))]TJ T* ( )Tj 0 -1.692 TD [(If you participate in both an MFSA and an HRA, funds will be deducted fr\ om each account based on your employer)-42(\222s plan design. If you are responsible for all or a portion of the in\ surance deductible )]TJ 0 -1.231 TD [(before employer HRA funds can be made available, you must submit an HRA \ Activation F)35(orm with an EOB to AmeriFlex once your portion is met as proof of the de\ ductible status. Once approved, the )]TJ T* (employer funded HRA will be activated.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 254.0342 Tm (Orthodontia Expenses:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 246.0342 Tm [(Y)109(our plan may reimburse advanced expenses for orthodontia made through a \ payment plan. Please contact your employer to see if th)(ese \223up)-17(-front)-27(\224 orthodontia expenses apply)86(. 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I certify that these expenses have not previously been reimbursed by t\ his or any other benefit plan, will not be )]TJ T* (reimbursed from any other source and will not be claimed as an income ta\ x deduction. I also understand that I may be asked to )Tj (provide further details \(i.e. a letter of medical necessity from a medi\ cal )Tj T* (practitioner certifying that the expense is to treat or cure a medical c\ ondition or a more detailed certification from me\). 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Please do not use a highlighter on claim form, receip\ ts,)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 358.0342 Tm (1\) Complete all applicable sections, sign and date. Services must be in\ curred in order to be reimbursed.)Tj 0 -1.231 TD (2\) Attach all required documentation )Tj /T1_0 1 Tf (\(New in 2011: For an OTC medicine, please include a copy of your medica\ l provider\222s prescription or a pharmacy receipt showing )Tj (the prescription #\))Tj /T1_3 1 Tf 83.754 0 Td (. )Tj -83.754 -1.231 Td (3\) Mail, fax or email the completed claim form \(scanned with signature\ if necessary\) to AmeriFlex.)Tj T* (4\) Please allow 2-3 weeks for paper check delivery or 7-10 days for dir\ ect deposits from the processing date.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 320.0342 Tm (MFSA/HRA Expenses - Acceptable forms of documentation include:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 312.0342 Tm [(1\) Explanation of Benefits \(EOB\): Y)109(our insurance carrier sends you an EOB each time a claim is filed. An EO\ B indicates your personal obligation via co)-19(-insurance or a deductible.)]TJ 0.001 -1.231 Td [(2\) R)17(eceipts: Include name of person treated; date expense was incurred; type\ of service; provider name; and amount of expense. \(IRS)( does not allow credit card receipts\))]TJ T* ( )Tj 0 -1.692 TD [(If you participate in both an MFSA and an HRA, funds will be deducted fr\ om each account based on your employer)-42(\222s plan design. If you are responsible for all or a portion of the in\ surance deductible )]TJ 0 -1.231 TD [(before employer HRA funds can be made available, you must submit an HRA \ Activation F)35(orm with an EOB to AmeriFlex once your portion is met as proof of the de\ ductible status. Once approved, the )]TJ T* (employer funded HRA will be activated.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 254.0342 Tm (Orthodontia Expenses:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 246.0342 Tm [(Y)109(our plan may reimburse advanced expenses for orthodontia made through a \ payment plan. Please contact your employer to see if th)(ese \223up)-17(-front)-27(\224 orthodontia expenses apply)86(. Orthodontia expenses)]TJ 74.056 0 Td ( )Tj -74.057 -1.231 Td [(require that both of the following be submitted with the intial claim: \(\ 1\) proof of payment \(e.g)17(. cancelled check, provider bill indicating payments or credit card rece\ ipt\); and \(2\) a copy of the )]TJ T* (orthodontia contract, including amount, down payment, monthly fees and e\ stimated length of treatment.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 215.0342 Tm [(Dependent Day Care Expenses \(R)17(eimbursed only after service is provided\) - Acceptable forms of documen\ tation include:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 207.0342 Tm [(R)17(eceipts including the name of the person for whom the service was provid\ ed, date expense was incurred, type of service, name of)( provider)100(, amount charged and the provider)-43(\222s tax ID number/SSN)45(. )]TJ T* (If you are using a private provider \(i.e. babysitter\) the receipt must\ also include their full name, signature, address and SSN)Tj ( \(IRS does not allow credit card receipts or statements as eligible pro\ of of )Tj T* (expense\). If you have recurring dependent day care expenses, you can ge\ t recurring reimbursement without having to file a claim)Tj ( after each date of service. To set up a recurring claim, you must provi\ de)Tj 0 -1.2 TD (the date range of services that will be provided and a note/statement fr\ om your provider outlining the schedule of expenses for)Tj ( the entire period of the recurring claim. Your first expense must be )Tj T* (substantiated after the service has been provided before you can set up \ a recurring claim. )Tj /T1_0 1 Tf 7 0 0 7 34.6665 162.5342 Tm [(Commuter/T)81(ransportation Expenses:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 153.5342 Tm (The IRS does not permit reimbursement for expenses older than 180 days f\ rom the date incurred.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 138.5342 Tm [(T)100(o avoid delays in reimbursement, please sign and date this claim form an\ d provide notice of any name or address change)1( to AmeriFlex.)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 130.5342 Tm [(I authorize my account\(s\) to be reduced by the amount requested. T)118(o the best of my knowledge and belief)35(, the statements on this form are complete and true. I am claiming reimb\ ursement only for )]TJ 0 -1.231 TD [(eligible expenses incurred by eligible plan participants during the appl\ icable plan year)99(. I certify that these expenses have not previously been reimbursed by t\ his or any other benefit plan, will not be )]TJ T* (reimbursed from any other source and will not be claimed as an income ta\ x deduction. I also understand that I may be asked to )Tj (provide further details \(i.e. a letter of medical necessity from a medi\ cal )Tj T* (practitioner certifying that the expense is to treat or cure a medical c\ ondition or a more detailed certification from me\). I u)Tj [(nderstand that if my claim is for expenses incurred during a Grace P)53(eriod: \(1\) )]TJ T* [(the expenses will be reimbursed first from available amounts remaining a\ t the end of the preceding Plan Y)109(ear and then during the Current Plan Y)108(ear; \(2\) claims are paid in the order in which they are )]TJ T* [(approved; and \(3\) once paid, a claim will not be reprocessed or otherw\ ise re)-17(-)-19(characterized so as to change the Plan Y)109(ear from which funds are taken to pay it.)]TJ /T1_0 1 Tf 11 0 0 11 34.6665 386.8701 Tm (Instructions )Tj ET EMC Q endstream endobj 858 0 obj <>/Font<>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream q /OC BMC q 1 0 0 1 576.7773 631.103 cm 0.129 0.118 0.443 rg /GS0 gs 0 0 m -544.903 -0.171 l -544.903 12.875 l 0 13.046 l h f Q BT 1 1 1 rg /GS0 gs /T1_0 1 Tf 0 Tc 0 Tw 0 Ts 100 Tz 0 Tr 9 0 0 9 36.6353 634.3555 Tm (Medical Expense Claims \(MFSA, or Employer funded HRA\) )Tj ET q 1 0 0 1 84.4868 630.9321 cm 0.004 0.004 0.004 RG 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/T1_0 1 Tf 7 0 0 7 526.7295 460.2441 Tm (Amount)Tj -0.51 -1.043 Td (Requested)Tj /TT0 1 Tf -68.882 7 Td ( )Tj /T1_0 1 Tf 9.249 -5.991 Td (Date\(s\) of Service)Tj T* (From To)Tj /TT0 1 Tf 2.348 -0.071 Td [( )-3507( )]TJ 5.5 0 0 5.5 351.333 484.5 Tm ( )Tj /T1_0 1 Tf 7 0 0 7 421.6973 547.7275 Tm (Type of Service)Tj 5.5 0 0 5.5 368.7705 540.6274 Tm ( \(Day Care, Pre-K, Day Camp, etc\))Tj 0.004 0.004 0.004 rg /T1_1 1 Tf 8.2 0 0 8.2 38.6079 5.4775 Tm (AMERI)Tj /T1_2 1 Tf (FLEX)Tj /T1_1 1 Tf 6.044 0 Td [( )122(302 Fellowship Road, Suite 100, Mount Laurel, NJ 08054 Toll-Free: 888.8\ 68.FLEX \(3539\) Fax: 888.631.1038 www.flex125.com)]TJ 1.934 0 Td ( )Tj 0 0 0 rg 9 0 0 9 35.8335 69.5 Tm (Employee Signature:)Tj ET q 1 0 0 1 133.064 69.4375 cm 0.004 0.004 0.004 RG 0.75 w 0 0 m 288.77 0.063 l S Q BT /TT0 1 Tf 10 0 0 10 427.5 69.167 Tm ( )Tj /T1_1 1 Tf 9 0 0 9 430.2783 69.167 Tm (Date:)Tj 0.929 0.11 0.141 rg -43.908 -1.43 Td (Mail Claim to:)Tj 0.004 0.004 0.004 rg 7.543 0.006 Td (AmeriFlex Claims 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Please do not use a highlighter on claim form, receip\ ts,)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 358.0342 Tm (1\) Complete all applicable sections, sign and date. Services must be in\ curred in order to be reimbursed.)Tj 0 -1.231 TD (2\) Attach all required documentation )Tj /T1_0 1 Tf (\(New in 2011: For an OTC medicine, please include a copy of your medica\ l provider\222s prescription or a pharmacy receipt showing )Tj (the prescription #\))Tj /T1_3 1 Tf 83.754 0 Td (. )Tj -83.754 -1.231 Td (3\) Mail, fax or email the completed claim form \(scanned with signature\ if necessary\) to AmeriFlex.)Tj T* (4\) Please allow 2-3 weeks for paper check delivery or 7-10 days for dir\ ect deposits from the processing date.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 320.0342 Tm (MFSA/HRA Expenses - Acceptable forms of documentation include:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 312.0342 Tm [(1\) Explanation of Benefits \(EOB\): Y)109(our insurance carrier sends you an EOB each time a claim is filed. An EO\ B indicates your personal obligation via co)-19(-insurance or a deductible.)]TJ 0.001 -1.231 Td [(2\) R)17(eceipts: Include name of person treated; date expense was incurred; type\ of service; provider name; and amount of expense. \(IRS)( does not allow credit card receipts\))]TJ T* ( )Tj 0 -1.692 TD [(If you participate in both an MFSA and an HRA, funds will be deducted fr\ om each account based on your employer)-42(\222s plan design. If you are responsible for all or a portion of the in\ surance deductible )]TJ 0 -1.231 TD [(before employer HRA funds can be made available, you must submit an HRA \ Activation F)35(orm with an EOB to AmeriFlex once your portion is met as proof of the de\ ductible status. Once approved, the )]TJ T* (employer funded HRA will be activated.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 254.0342 Tm (Orthodontia Expenses:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 246.0342 Tm [(Y)109(our plan may reimburse advanced expenses for orthodontia made through a \ payment plan. Please contact your employer to see if th)(ese \223up)-17(-front)-27(\224 orthodontia expenses apply)86(. Orthodontia expenses)]TJ 74.056 0 Td ( )Tj -74.057 -1.231 Td [(require that both of the following be submitted with the intial claim: \(\ 1\) proof of payment \(e.g)17(. provider bill indicating payments or credit card receipt\); and \(2\) \ a copy of the )]TJ T* (orthodontia contract, including amount, down payment, monthly fees and e\ stimated length of treatment.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 215.0342 Tm [(Dependent Day Care Expenses \(R)17(eimbursed only after service is provided\) - Acceptable forms of documen\ tation include:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 207.0342 Tm [(R)17(eceipts including the name of the person for whom the service was provid\ ed, date expense was incurred, type of service, name of)( provider)100(, amount charged and the provider)-43(\222s tax ID number/SSN)45(. )]TJ T* (If you are using a private provider \(i.e. babysitter\) the receipt must\ also include their full name, signature, address and SSN)Tj ( \(IRS does not allow credit card receipts or statements as eligible pro\ of of )Tj T* (expense\). 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Your first expense must be )Tj T* (substantiated after the service has been provided before you can set up \ a recurring claim. )Tj /T1_0 1 Tf 7 0 0 7 34.6665 162.5342 Tm [(Commuter/T)81(ransportation Expenses:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 153.5342 Tm (The IRS does not permit reimbursement for expenses older than 180 days f\ rom the date incurred.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 138.5342 Tm [(T)100(o avoid delays in reimbursement, please sign and date this claim form an\ d provide notice of any name or address change)1( to AmeriFlex.)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 130.5342 Tm [(I authorize my account\(s\) to be reduced by the amount requested. T)118(o the best of my knowledge and belief)35(, the statements on this form are complete and true. I am claiming reimb\ ursement only for )]TJ 0 -1.231 TD [(eligible expenses incurred by eligible plan participants during the appl\ icable plan year)99(. I certify that these expenses have not previously been reimbursed by t\ his or any other benefit plan, will not be )]TJ T* (reimbursed from any other source and will not be claimed as an income ta\ x deduction. I also understand that I may be asked to )Tj (provide further details \(i.e. a letter of medical necessity from a medi\ cal )Tj T* (practitioner certifying that the expense is to treat or cure a medical c\ ondition or a more detailed certification from me\). I u)Tj [(nderstand that if my claim is for expenses incurred during a Grace P)53(eriod: \(1\) )]TJ T* [(the expenses will be reimbursed first from available amounts remaining a\ t the end of the preceding Plan Y)109(ear and then during the Current Plan Y)108(ear; \(2\) claims are paid in the order in which they are )]TJ T* [(approved; and \(3\) once paid, a claim will not be reprocessed or otherw\ ise re)-17(-)-19(characterized so as to change the Plan Y)109(ear from which funds are taken to pay it.)]TJ /T1_0 1 Tf 11 0 0 11 34.6665 386.8701 Tm (Instructions )Tj ET EMC Q endstream endobj 931 0 obj <> endobj 932 0 obj <> endobj 933 0 obj <> endobj 934 0 obj <> endobj 935 0 obj <> endobj 936 0 obj <> endobj 937 0 obj <>stream HWn}/T!~K8EtVG(Y8E/kSޝd$qｊ9-*Fp\pWc4 uѡ'ã,4/x="bF4[k_k'y3XdqWkk-L:ey7cv.Jv:.F./'=v>9ޕw5e;烳ŠQ+°=c,洡눭ו氭.>륱"M޳<ӞKJy2K6x~(is<.aIlNvV,fi@u2|^ˣ6g~2H8~aZ*n(EJrmZj>1>[ۨIF% B &ͺ2 GŴ># -qh챫o|R {\o ~i')$r 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709.1665 cm 0.067 0 0 rg 0 0 m 256.667 0 l h f Q q 1 0 0 1 127.3325 709.1665 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 127.3325 695.1665 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 127.333 680.5 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 127.3325 666.5 cm 0 0 m 256.667 0 l S Q q 1 0 0 1 134.999 572.501 cm 0 0 0 rg 0 0 m 0 58.432 l h f Q q 1 0 0 1 134.9995 630.9321 cm 0 0 0 RG 0 0 m 0 -58.432 l S Q Q BT 0 0 0 rg /T1_0 1 Tf 7 0 0 7 137.4346 622.5996 Tm ( Name of Person )Tj 0 -1.114 TD (Receiving Medical Service)Tj ET q 0 0 612 792 re W n q 1 0 0 1 169.167 559.2832 cm 0.067 0 0 RG 1 w 0 0 m 0 -48.783 l S Q Q BT /T1_0 1 Tf 7 0 0 7 34.6665 375.0342 Tm (Please read carefully and be sure your claim is completed in its entiret\ y to ensure ther)Tj 0 -1.2 TD (or any documents included as backup as this may cause a delay in process\ ing your claim. )Tj 39.141 1.2 Td [(e)-1( is no de)1(lay in processing. Please do not use a highlighter on claim form, receip\ ts,)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 358.0342 Tm (1\) Complete all applicable sections, sign and date. Services must be in\ curred in order to be reimbursed.)Tj 0 -1.231 TD (2\) Attach all required documentation )Tj /T1_0 1 Tf (\(New in 2011: For an OTC medicine, please include a copy of your medica\ l provider\222s prescription or a pharmacy receipt showing )Tj (the prescription #\))Tj /T1_3 1 Tf 83.754 0 Td (. )Tj -83.754 -1.231 Td (3\) Mail, fax or email the completed claim form \(scanned with signature\ if necessary\) to AmeriFlex.)Tj T* (4\) Please allow 2-3 weeks for paper check delivery or 7-10 days for dir\ ect deposits from the processing date.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 320.0342 Tm (MFSA/HRA Expenses - Acceptable forms of documentation include:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 312.0342 Tm [(1\) Explanation of Benefits \(EOB\): Y)109(our insurance carrier sends you an EOB each time a claim is filed. An EO\ B indicates your personal obligation via co)-19(-insurance or a deductible.)]TJ 0.001 -1.231 Td [(2\) R)17(eceipts: Include name of person treated; date expense was incurred; type\ of service; provider name; and amount of expense. \(IRS)( does not allow credit card receipts\))]TJ T* ( )Tj 0 -1.692 TD [(If you participate in both an MFSA and an HRA, funds will be deducted fr\ om each account based on your employer)-42(\222s plan design. If you are responsible for all or a portion of the in\ surance deductible )]TJ 0 -1.231 TD [(before employer HRA funds can be made available, you must submit an HRA \ Activation F)35(orm with an EOB to AmeriFlex once your portion is met as proof of the de\ ductible status. Once approved, the )]TJ T* (employer funded HRA will be activated.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 254.0342 Tm (Orthodontia Expenses:)Tj /T1_3 1 Tf 6.5 0 0 6.5 34.6665 246.0342 Tm [(Y)109(our plan may reimburse advanced expenses for orthodontia made through a \ payment plan. Please contact your employer to see if th)(ese \223up)-17(-front)-27(\224 orthodontia expenses apply)86(. Orthodontia expenses)]TJ 74.056 0 Td ( )Tj -74.057 -1.231 Td [(require that both of the following be submitted with the initial claim: \ \(1\) proof of payment \(e.g.)535( provider bill indicating payments or credit card receipt\); and \(2\)\ a copy of the )]TJ T* (orthodontia contract, including amount, down payment, monthly fees and e\ stimated length of treatment.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 215.0342 Tm [(Dependent Day Care Expenses \(R)17(eimbursed only after service is provided\) - Acceptable forms of documen\ tation include:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 207.0342 Tm [(R)17(eceipts including the name of the person for whom the service was provid\ ed, date expense was incurred, type of service, name of)( provider)100(, amount charged and the provider)-43(\222s tax ID number/SSN)45(. )]TJ T* (If you are using a private provider \(i.e. babysitter\) the receipt must\ also include their full name, signature, address and SSN)Tj ( \(IRS does not allow credit card receipts or statements as eligible pro\ of of )Tj T* (expense\). If you have recurring dependent day care expenses, you can ge\ t recurring reimbursement without having to file a claim)Tj ( after each date of service. To set up a recurring claim, you must provi\ de)Tj 0 -1.2 TD (the date range of services that will be provided and a note/statement fr\ om your provider outlining the schedule of expenses for)Tj ( the entire period of the recurring claim. Your first expense must be )Tj T* (substantiated after the service has been provided before you can set up \ a recurring claim. )Tj /T1_0 1 Tf 7 0 0 7 34.6665 162.5342 Tm [(Commuter/T)81(ransportation Expenses:)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 153.5342 Tm (The IRS does not permit reimbursement for expenses older than 180 days f\ rom the date incurred.)Tj /T1_0 1 Tf 7 0 0 7 34.6665 138.5342 Tm [(T)100(o avoid delays in reimbursement, please sign and date this claim form an\ d provide notice of any name or address change)1( to AmeriFlex.)]TJ /T1_3 1 Tf 6.5 0 0 6.5 34.6665 130.5342 Tm [(I authorize my account\(s\) to be reduced by the amount requested. T)118(o the best of my knowledge and belief)35(, the statements on this form are complete and true. I am claiming reimb\ ursement only for )]TJ 0 -1.231 TD [(eligible expenses incurred by eligible plan participants during the appl\ icable plan year)99(. I certify that these expenses have not previously been reimbursed by t\ his or any other benefit plan, will not be )]TJ T* (reimbursed from any other source and will not be claimed as an income ta\ x deduction. I also understand that I may be asked to )Tj (provide further details \(i.e. a letter of medical necessity from a medi\ cal )Tj T* (practitioner certifying that the expense is to treat or cure a medical c\ ondition or a more detailed certification from me\). I u)Tj [(nderstand that if my claim is for expenses incurred during a Grace P)53(eriod: \(1\) )]TJ T* [(the expenses will be reimbursed first from available amounts remaining a\ t the end of the preceding Plan Y)109(ear and then during the Current Plan Y)108(ear; \(2\) claims are paid in the order in which they are )]TJ T* [(approved; and \(3\) once paid, a claim will not be reprocessed or otherw\ ise re)-17(-)-19(characterized so as to change the Plan Y)109(ear from which funds are taken to pay it.)]TJ /T1_0 1 Tf 11 0 0 11 34.6665 386.8701 Tm (Instructions )Tj ET EMC endstream endobj 939 0 obj <> endobj 940 0 obj <> endobj 941 0 obj <> endobj 942 0 obj <>stream HU XSWK&//PܦԱ(u-Y pCZlhնmG֥uLHкj Qs={{ (F {kbY:CA"|рs6g=g.V@:=(%wקR.-2a|0%8ygΞ;7\v7LR1gNo>-UdSi,/1J$$ґIҩҕAeA|5|ߋX~_/JRT)5ʞ)5*NjQuPU!!**UͩJ' ^: ]P_JRBV pD8.. ׅ;h M&YlB-c+N2R`d)ꠒG ٌ`0QY1S2HR8a0AP+lcp1D1Hd4f|m5(g;ff Mw:zkLKZˬkY馫c-kޖ KQcgKmچ @v{E0a*CHsy`syy9lVۛڣLMML'%72LcML#MS)Tv񜎶+ho_}bvƷ1\hn(6b-a cla1Vc֡$h;w'،Op)!HYkEy\} +qRd 3Ld9 rYGfEy؄^B$#'r&k&E \3j[\(a{1a_X_PڗO,,wfrY{.4qlǮDF~B+wO8JLd޾]m;S Kx[hufnf^nfJu2 WN^ci?/O}X~ׅSGo͍FQ-_{kћx5΍_F%. zҪTku͚C#j-Ԫ>V YB P ʁF`NuShw,%d.vΡͰ21%]CY#@3|R Q4%fπ$9j^ejdHqM>~^g}Zja=k Qn2I^,Hs~ uC?(4cp.|fģى:~|9'pY' K4n YȢ _yd1|8-%3

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