request


Please make the following payments for Eligible Medical Expenses from my HSA Medical Care Savings Account. Unless I have indicated that the Eligible Medical Expense has been paid by me and I should be reimbursed directly, please make all payments directly to the provider indicated. attached are true and correct copies of third-party statements (invoices, receipts or insurance processing forms) which contain all of the following: patient name, date of service, service provider, description of service, and amount of expense that is un-reimbursable by insurance.


Patient	Date of Service	Doctor, Hospital or other Provider	Description	Amount	Pay to Account Holder if Checked [x]

I certify that the above items have not been reimbursed and are not reimbursable under any medical insurance coverage. I authorize you to obtain any information needed from third-party providers to process claim. __________________________________ ____________________________ Account Holder Signature Date A THIRD-PARTY STATEMENT (INVOICES OR RECEIPTS, FOR EXAMPLE) CONTAINING THE ABOVE INFORMATION MUST BE ATTACHED. PLEASE SUBMIT THE COMPLETED FORM WITH THE REQUIRED INFORMATION AND MAIL TO HSA AT THE ADDRESS LISTED ABOVE.

I certify that the above items have not been reimbursed and are not reimbursable under any medical insurance coverage. I authorize you to obtain any information needed from third-party providers to process claim.

__________________________________ ____________________________
Account Holder Signature Date

A THIRD-PARTY STATEMENT (INVOICES OR RECEIPTS, FOR EXAMPLE) CONTAINING THE ABOVE INFORMATION MUST BE ATTACHED. PLEASE SUBMIT THE COMPLETED FORM WITH THE REQUIRED INFORMATION AND MAIL TO HSA AT THE ADDRESS LISTED ABOVE.