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FSA Healthcare Reimbursement
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Resources

Healthcare Reimbursement

Download the Form


The HealthCare Reimbursement form is used when submitting for any medical services reimbursement from your Flexible Spending Account (FSA). The form should be printed, completed and submitted along with all corresponding receipts to EHIM’s Flexible Spending Department.

EHIM
Attn: FSA Department
248-204-6350

If you have any questions about how to complete the form please feel free to contact EHIM at 800-311-3446.

  • Member Information
    • Special Medical Reimbursement Program
    • FSA Management
    • HRA Management
    • Debit Card Program
    • Dental Plan Administration
    • FAQs
  • Downloadable Forms
  • Employer
    • COBRA Event
    • Enrollment or Termination
    • Medicare Part D Forms
  • Member
    • Clinical Medical Release
    • FSA Dependent Care Reimbursement
    • FSA Healthcare Reimbursement
    • HRA Reimbursement Form
    • HRA Rx Reimbursement Form
    • HIPAA Forms
    • Medical Information Release
    • OptumRx Mail Order
    • Prescription Reimbursement
    • Prior Authorization
    • Quantity Limit Medical Necessity PPI
    • Quantity Limit Medical Necessity Request
    • Step Therapy Medical Necessity
    • Walgreens Mail Order Registration
    • Walgreens Mail Order Physician Fax
    • Formulary
  • Pharmacy
    • MAC List Appeal Form
    • TN Standard Pharmacy Reimbursement Form for Actual Cost Appeals

Resources

Healthcare Reimbursement

Download the Form


The HealthCare Reimbursement form is used when submitting for any medical services reimbursement from your Flexible Spending Account (FSA). The form should be printed, completed and submitted along with all corresponding receipts to EHIM’s Flexible Spending Department.

EHIM
Attn: FSA Department
248-204-6350

If you have any questions about how to complete the form please feel free to contact EHIM at 800-311-3446.

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