The Health Care Reimbursement form is to be used when submitting for any medical services reimbursement from your Flexible Spending Account (FSA) account.
Download the form (PDF).
The form should be printed, completed and submitted along with all corresponding receipts to EHIM’s Flexible Spending Department.
You may remit your FSA Reimbursement requests to EHIM through the mail
or by fax:
Attn: FSA Department
If you have any questions about how to complete the form please feel free to contact EHIM at 800-311-3446.