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Instructions
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Employee must complete Employee Information.
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Complete this Request for Reimbursement Form in its entirety. Please ensure your supporting documentation clearly indicates the requested amount.
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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.
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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.
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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.
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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.
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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.
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Sign and date Employee Certification.
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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.