Instructions
Employee must complete Employee Information.
Complete this Request for Reimbursement Form in its entirety. Please ensure your supporting documentation clearly indicates the requested amount.
Check the appropriate box in the Supporting Documentation section and submit Acceptable Supporting Documentation as described below. (When attaching small receipts, we suggest you tape them to a standard size sheet of paper.) Send copies of supporting documentation along with this form. Keep original receipts and other documents for your records.
a) For office visits – An Explanation of Benefits (EOB) statement from your insurance carrier, OR an itemized receipt or bill from the provider that includes the provider’s name, patient’s name, a description of the service, the original date of the service*, and your portion of the charge.
b) For prescription drug purchases – A pharmacy statement or receipt from your pharmacy including the patient’s name, the Rx number, the name of the drug, the date the prescription was filled, and the amount.
c) For over-the-counter (OTC) medicines – A written OTC prescription along with an itemized cash register receipt that includes the merchant name, name of the OTC medicine or drug, purchase date, and amount, OR a printed pharmacy statement or receipt from a pharmacy that includes the patient’s name, the Rx number, the date the prescription was filled, and the amount.
d) For over-the-counter health care-related products – An itemized cash register receipt with the merchant name, name of the item/product, date, and amount.
Please Note: Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.
Sign and date Employee Certification.
Submit reimbursement form and copies of supporting documentation to Anthem Blue Cross and Blue Shield
(Anthem) Flexible Benefits Services:
Fax: (866) 538-6972 Phone: (877) 451-7244 P.O. Box 660165 Dallas, TX 75266-0165
Note: Download "Flexible Spending Account Claim Form" on this page.