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Home My WebLink Aboutflexclaim-4001-7047-3202 Adlbh. ■ �IIIIOV� uNNpIVUVUVU,�Vu r�q% I " IIIIII�� nM REQUEST FOR 18951 ti4ti44o.S to ��uuuuumui ,uuIII��IIIM��, IIIIIIIIII REIMBURSEMENT Client Name Oak Park Heights, City Of Participant TASC Id 4001 - 7047 -3202 PLEASE DUPLICATE THIS FORM FOR FUTURE REQUESTS Submit Request for Reimbursement: ERIC JOHNSON For claims submitted online: only print and fax the Veriflex Coversheet from 620 OAKWOOD ST S the web along with your receipts to the fax number located on the cover sheet. BAYPORT MN 55003 Claims submitted with RFR Form should be sent to TASC: a. By Fax: 608 - 663 -2762 b. Or by Mail: TASC PO BOX 7308 Madison, WI 53707 -7308 ❑ New Address, check here and update - please print WRITE LEGIBLY AND DO NOT HIGHLIGHT AMOUNTS If updates were sent previously, please use your new updated RFR form ON YOUR RECEIPT ALL BOXES AND FIELDS MUST BE COMPLETED SUBMIT A COPY OF YOUR RECEIPT ALONG WITH THIS RFR ONLY FOUR LINES PER FORM WILL BE PROCESSED Receipt Date of Service (not Benefit Service Type Attached billing or paid date) Code* Code ** Request Amount Service Provider(s) ❑ ❑� ❑�❑ U W I I I I I•W ❑ WA WAW ❑ W I I I I I W ❑ ❑A ❑A❑ U W I I I I I W ❑ WA WAW ❑ W I I I I I W BENEFIT CODES D - Dependent Care Expenses SERVICE CODES DC - Dependent Care To the best of my knowledge and belief, my statements on this Request for Reimbursement are complete and true. I am requesting reimbursement only for eligible expenses incurred during the applicable Plan Year and for eligible Plan Participants. I certify that these expenses have not been previously reimbursed under this or any other benefit plan and will not be claimed as an income tax deduction. I understand that the IRS regulates my FlexSystem account and that these guidelines are implemented as a means of ensuring compliance and approval for reimbursement. I further understand that it is my responsibility to comply with these guidelines and to avoid submitting duplicate or ineligible requests, as doing so may delay payment. I authorize my Flexible Spending Account balance to be reduced by the amount requested. Employee Signature (required) Date ❑ / ❑ / ❑ 4001 - 7047 -3202 18951 ■ ftix� ■ F , ^ "aNtlr X )' ' Ste II I T S C REIMBURSEMENT TIPS Tips to ensure prompt and accurate reimbursements. • Incomplete Requests for Reimbursement will be denied. • Use only your personalized Request for Reimbursement Form. Please duplicate this Form for future requests. (Non - conforming reimbursement forms will be rejected. ) One request form can be used for multiple expenses. • When completing the Request for Reimbursement Form enter each different expense on a separate line, identifying the date of service, the benefit type, the service type, and the service provider. Dates of Service always represents the date your services are incurred or rendered. • Enter the appropriate benefit and service codes. See front side for a list of codes. • Enter the amount requested for each Benefit Code in the Request Amount field for that benefit. • You must sign each Request for Reimbursement Form and /or VeriFlex Cover Sheet submitted to FlexSystem. • Although reimbursements may be processed prior to expense substantiation (if offered by your employer, all medical expenses must be substantiated by the Participant and verified by FlexSystem. Fax or mail copies of the receipts with your Request for Reimbursement Form to FlexSystem at 608 - 663 -2762 or to TASC, P.O. Box 7308, Madison, WI 53707 -7308. • For quickest reimbursement, Requests for Reimbursement may be submitted on -line at wwwtasconline.com. If submitting on -line, please use the VeriFlex Cover Sheet (available from the web after submission of the Request for Reimbursement) instead of this Form. • All Participants are expected to maintain supporting records and documents to validate the expense type and amount. FlexSystem may require additional information or documentation prior to processing a claim. • FlexSystem daily processes Requests for Reimbursement, which when received at TASC by noon CST will be processed that business day, with a corresponding payment issued the following business day. • Access Participants' account status information on the Internet (at wwwtasconline.com), or on FlexSystems Interactive Voice Response System (at 1 - 800 - 422 - 4661). Participants will need their Client ID, Participant ID and Pin Number to access this information. --------------------------------------- "If " S S REQUEST FOR REIMBURSEMENT For each request entered, all boxes must be completed. Please check the appropriate box to indicate all attached receipts or substantiating documents. Date of Service (not Service Rec. billing or paid date) Benefit Type Attach Month Day Year Code Code Request Amount Service Provider(s) O I 1 12 10 11 I I 0 1 I M� I R IX I I 11 1 3 J 11 18 1 Wal 0 I 1 12 1 IO II 0 1 I CJ I C IP 1 IO I I 1 010 Dr. Jones _ I 0 I 1 12 11 11 II 0 13 IM I I D 1P I I 1 1 6 1.1 9 19 I Dr. Carter I Q It 12 1 I I 0 13 I DU D IC I 1 2 10 1 8 1 13 I Kid Keepers Center I BENEFIT CODES NI - MEDICAL EXPENSE - OUT OF POCKET D - DEPENDENT CARE /DAY CARE TASC • 2302 International Lane • Madison, WI 53704 -3140 • 1- 800 - 422 -4661 • Fax: 608 - 245 -3623 • serviceLtasconline.com .................................................................................................................................................................................................................................................. ............................... The information in this communication is confidential and may only be used by the authorized recipient for its intended purpose. Any other use or disclosure is prohibited. FX -3073- 110607