Phone:
901-756-8244 |
Toll-free:
1-800-737-0125 |
Fax:
901-756-8322 |
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When filing your claim, you must attach copies of the receipts.
The receipt must include the service provider's name and the date
and type of service for each expense. Canceled checks, credit
card slips, or statements of balance due are
not acceptable.
If you fax your claim forms and receipts, please do not follow up with a hardcopy.
Always retain a copy of all forms and receipts. You may make copies of the blank form for your future use.
| Flexible Spending Account (FSA). Use this claim form for out-of-pocket FSA expenses ONLY.
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| Health Reimbursement Arrangement (HRA). Use this claim form for HRA expenses ONLY.
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| Flexible Spending Account / Health Reimbursement Arrangement (FSA/HRA). Use this form for FSA and/or HRA Debit Card charges.
Letter of Medical Necessity. This form should be completed by the attending physician to confirm treatment is necessary for a specific medical condition.
Direct Deposit Form. This completed form will enable us to deposit your reimbursement directly into your bank account.
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