INSTRUCTIONS: REQUEST FOR REIMBURSEMENT FORM FOR FLEXIBLE HEALTH CARE ACCOUNT
Alabama public employees who have a flexible health care account within the state's PEEHIP health insurance program and who wish to file a request for reimbursement can do so using the form discussed in this article. This document can be obtained from the website maintained by the Retirement Systems of Alabama.
Request For Reimbursement Form For Flexible Health Care Account Step 1: At the top of the form, sign and date where indicated.
Request For Reimbursement Form For Flexible Health Care Account Step 2: Section 1 concerns information about the employee. In the first box, enter your first name.
Request For Reimbursement Form For Flexible Health Care Account Step 3: In the second box, enter your middle initial.
Request For Reimbursement Form For Flexible Health Care Account Step 4: In the third box, enter your last name.
Request For Reimbursement Form For Flexible Health Care Account Step 5: In the fourth box, enter the month of your date of birth.
Request For Reimbursement Form For Flexible Health Care Account Step 6: In the fifth box, enter the date of your date of birth.
Request For Reimbursement Form For Flexible Health Care Account Step 7: In the sixth box, enter the year of your date of birth.
Request For Reimbursement Form For Flexible Health Care Account Step 8: In the seventh and eighth boxes, enter your preferred blue account number.
Request For Reimbursement Form For Flexible Health Care Account Step 9: In the ninth box, enter your company name.
Request For Reimbursement Form For Flexible Health Care Account Step 10: In the tenth box, enter your work phone number.
Request For Reimbursement Form For Flexible Health Care Account Step 11: In the eleventh box, enter your home phone number.
Request For Reimbursement Form For Flexible Health Care Account Step 12: Section II concerns information about the reimbursement you are seeking. You may seek reimbursement for up to five different instances of care. In the left column for each, fill in the oval next to the type of service you are seeking reimbursement for.
Request For Reimbursement Form For Flexible Health Care Account Step 13: In the section on the right, provide all requested information about the type of service you are seeking reimbursement for. Attach all appropriate supporting documentation.
