Enrollment Form
Claim Form
Expense Worksheet
Direct Deposit Form
Dependent Care Auto Payment Form
Web Access and Online Claim Instructions
Sample of Eligible Expense Sheet
Caf (10/2012)
Mail to: P.O. Box 651366, Salt Lake City, UT 84165-1366
Fax: (801)483-0798
Email: claims@abgrm.com
Website: abgrm.com
Flexible Spending Account Enrollment Packet
In order to participate in a cafeteria plan you must complete the enrollment form and submit it to your HR department.
To access your funds from the cafeteria plan you must complete a claim form. Please submit a signed copy to Alliance Benefit Group-Rocky Mountain by mail, email, fax or online with itemized copies of your receipts.
Use this form to set up and maintain an automatic continual payment of dependent care expenses. A completed form must be sent to Alliance Benefit Group Rocky Mountain to begin the payments. This form must also be
submitted each quarter to ABG with receipts verifying services to continue the program.
The following forms are included in this enrollment packet:
This form is designed to assist you in identifying your out of pocket medical expenses. The form will give you a fairly accurate projection of what you should elect on your Health FSA. This form should not be submitted.
Direct deposit can be a fast and efficient way to receive your cafeteria funds. In order to set up a new direct deposit, or update your current account, you must complete this form and submit it to ABG. If you would like an email notification when a deposit is generated please include your email address on the form.
We offer 24 hour online access to your account. This form will give instructions on how to access the website and step by step instructions on filing a claim online.
This worksheet will give you an overview of general categories of eligible and non-eligible expenses. To view a more comprehensive list please go to our website at abgrm.com.
Employee Information (Print)
Elections
(Health FSA maximum is $2500 for all plan years beginning on or after January 1, 2013)Health FSA
I elect to participate. Annual Election $
I do not wish to participate. I would like to use a Debit Card * Debit card fee may apply
Dependent Care FSA
I elect to participate. Annual Election $
Maximum annual deduction is $5000 for married filing joint/$2500 for single
I do not wish to participate.
Direct Deposit Information
YES! I would like to have my reimbursement's direct deposited into my bank account Checking Account
Please attach a copy of a voided check. Deposit slips are only accepted for Saving Accounts Savings Account
Authorization
Caf (10/2012)
Flexible Spending Account Enrollment Form
By marking yes above I hereby authorize Alliance Benefit Group – Rocky Mountain to initiate credit entries for depositing my Flexible Spending Account reimbursements into my account designated above and, if necessary, make corrections for any entries to be made to my account in error. This authority is to remain in full force and effect until Alliance Benefit Group – Rocky Mountain has received written notification from me of its termination in such time and in such manner as to afford Alliance Benefit Group – Rocky Mountain a reasonable opportunity to act on it.
Alliance Benefit Group-Rocky Mountain P.O. Box 651366, Salt Lake City, UT 84165-1366
Employee Signature Date
I understand that by signing and submitting this form, I authorize the adjustment of my annual taxable salary based on my elections above, with the "tax protected" funds being transferred into my Flexible Spending Account. My election cannot be changed during the plan year, unless I experience an eligible change in status. Any unused amounts remaining in my account at the end of the plan year will be forfeited. However, I will have a specified period of time (indicated on the FSA Highlights) after the end of the plan year or date of my termination to submit receipts for reimbursement for services received during the plan year. I also certify that I, my spouse and/or dependent(s) if applicable, will only use the Flexible Spending Account in accordance with Section 213 of the Internal Revenue Code. I further certify that I will not seek reimbursement from any other plan for medical expense paid with the Flexible Spending Account, nor will I claim any federal income tax deduction with respect to such expense.
Financial Institution Routing Number (9 digits)
Financial institution's address Account Number
Company Name Employee Name Address, City, State, Zip
Phone (801)486-3087
Please submit this form to your Human Resource Department Employee Email Address
Social Security Number
_ _ _-_ _-_ _ _ _
Date of Hire (Required)Employee Information (Print)
Claim Instructions
2) Provide a copy of the receipt, bill, Explanation of Benefits (EOB) or statement as proof of service. Check register's, bank statement and credit card receipts are not valid forms of proof of service. 3) A receipt must show date, amount, service provided and provider to be valid.
4) Minimum payment of $25 (Exception only when available funds are less then $25 and payment will empty the account).
Medical Expenses
(including Health, Dental, Vision and Pharmacy)Dependent Care Expenses
Employee Signature
Caf (10/2012)
Email: claims@abgrm.com Online Claim Website: abgrm.com
/ / $
Total
Total $
Employee Signature Date
Please return this form with receipts to: Alliance Benefit Group-Rocky Mountain (801)486-3087 Mail to: P.O. Box 651366, Salt Lake City, UT 84165-1366
Fax: (801)483-0798
/ / $
To the best of my knowledge , my statements on this Claim Form are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year. I certify that these expenses have not been previously reimbursed under this or any other benefit plan and will not be claimed as an income tax deduction. I authorize my Flexible Spending Account to be reduced by the amount requested.
/ / $
/ / $
$ Date of
Service Dependent ReceivingService Age Service Provider Amount
/ / $ / / $ / / $ / / $ / / $ / / $ / / $ / / $ Date of Service Individual Receiving Service
Service Type (Office Visit, RX, Dental, Vision, Orthodontia
etc.) Amount
Flexible Spending Account Claim Form
Employee Name Company Name Social Security Number
_ _ _-_ _-_ _ _ _
Address, City, State, Zip Phone Number
Email Address Address Change? No Yes
Medical Expenses
$ $ $ $ $ $ $ $ $ $Dental Expenses
$ $ $ $ $ $ $ $Vision Expenses
$ $ $ $ $ $Total Expenses
Caf (10/2012)Flexible Spending Account Expense
Worksheet
Copays
Doctors Office Visits
Pharmacy/RX
Hospitals
Deductibles
Chiropractors
Laboratory/Exams
X-Rays
Other
Total Medical Expenses
Lasik Surgery
Annual Cleanings
X-Rays
Fillings
Root Canals
Crowns
Orthodontia
Other
Total Dental Expenses
Eye Glasses
Contact Lenses
Exams
Please do not return this form
Per Pay period Deductions Alliance Benefit Group-Rocky Mountain (801)486-3087
Other
Total Dental Expenses
Employee Information (Print)
Form Instructions
1) Complete the employee information section including social security number. 2) Enter the financial information below including routing and account number.
3) Attach a copy of a voided check (deposit slips are only allowed for savings accounts). 4) Fax, email or mail the form to Alliance Benefit Group-Rocky Mountain.
5) Please allow 5 business days for your account to update, payments will issue as checks until updated.
Voided Check
Financial Information
Employee Authorization
Caf (10/2012) Savings Account Email: claims@abgrm.comRouting Number (9 digits) Account Number
Employee Signature Date
I hereby authorize Alliance Benefit Group–Rocky Mountain to initiate credit entries for depositing my Flexible Spending Account reimbursements into my account designated above and, if necessary, make corrections for any entries to be made to my account in error. This authority is to remain in full force and effect until Alliance Benefit Group–Rocky Mountain has received written notification from me of its termination in such time and in such manner as to afford Alliance Benefit Group–Rocky Mountain a reasonable opportunity to act on it.
Please return this form with reciepts to: Mail to: P.O. Box 651366, Salt Lake City, UT 84165-1366
Fax: (801)483-0798
Phone Number
Email Address Address Change?
Direct Deposit Payment Request Form
Alliance Benefit Group-Rocky Mountain (801)486-3087
No Yes
Employee Name Company Name Social Security Number
_ _ _-_ _-_ _ _ _
Address, City, State, ZipPlease attach copy of voided check here
Financial institution Name Financial Institution Address
Employee Information (Print)
Dependent Care Information
Provider Information
Employee Signature
Caf (10/2012)
Dependent Care Automatic Reimbursement
Form
Dependent Care Service Dates ____/____/____ To ____/____/____
Second Quarter Dependent Care Expenses $__________________________
Dependent Care Service Dates ____/____/____ To ____/____/____
$ $
IRS code section 129 states that reimbursement for expenses cannot occur prior to the service being provided. However it is allowed to be reimbursed ongoing as the services are rendered. To facilitate a continual reimbursement of dependent care funds as soon as they are deducted from your pay check you must complete this form and submit it with a signature from the provider. You will also need to submit this form each quarter to ABG by fax, mail or email with copies of receipts, bills or statements that show that the services have actually been provided. If receipts are not submitted prior to the first payroll after each quarter the automatic payment will terminate.
First Quarter Dependent Care Expenses $__________________________ Employee Name
Annual Dependent care deduction Number of Pay Period Per Pay Period Deduction
____/____/____ To ____/____/____
Fourth Quarter Dependent Care Expenses $__________________________
Dependent Care Service Dates ____/____/____ To ____/____/____ Third Quarter Dependent Care Expenses
$__________________________ Dependent Care Service Dates
Provider Address, City, State Zip Provider Signature
Provider Phone Number Date
Provider Name Service Dates of Contract
____/____/____ To ____/____/____
Fax: (801)483-0798 Email: claims@abgrm.com
I certify that the above information is accurate and correct. I also certify that the dependent care services will be continuous throughout the contract and if anything changes or terminates I will contact my plan administrator immediately. I agree to send in quarterly receipts to verify that the services have actually been rendered.
Employee Signature Date
Alliance Benefit Group Rocky Mountain (801)486-3087 Mail to: P.O. Box 651366, Salt Lake City, UT 84165-1366
Please return this form to:
Email Address Address Change? Yes
Person Receiving Care Employee Social Security Number
_ _ _-_ _-_ _ _ _
Address, City, State, Zip Phone Number
How to Access Participant Web
Participant Web Options
Online Web Claim
• Step One - Click on Claims and then on Claim Entry
A. Select Benefit, start and end date of service, service provider, description and the amount of the claim. B. Add claim amount and click . Each expense should be entered separately.
C. Click Save and Continue once you have added all of the expenses you wish to claim to move to the next step.
• Step Two - Documentation Submission
◦ Option One - Submit claim form and receipts via fax or mail. (Print a confirmation page on the next step)
◦ Option Two - Submit claim form and receipts as an attachment online. (Upload attachments on the next step)
◦ Option Three -This options saves the claim but will not pay out until documentation is submitted by option 1 or 2
• Step Three - Attach claim or print confirmation
◦ By choosing option 1, to print a confirmation page, you must submit the confirmation page and receipts by fax, mail or email to Alliance Benefit Group-Rocky Mountain.
◦ By choosing option 2 and attaching the receipts directly to the claim no further steps are required.
Web Claim Instructions
• View Available Balance
• View Annual Declared Amount
• View Year To Date Deposits and Claims • Input Claims and View Claim History • Change Password
• Internet address: https://www.abgrm.com
• Enter your user ID and password (the default user ID is your SS# and the password is the last 4 digits of your SS#). • The user ID and the password may be changed at any time. The user ID & password are case sensitive.
• Click on "PARTICIPANT" for help please contact our call center at (801)483-0798.
Alliance Benefit Group-Rocky Mountain (801)486-3087 Mail to: P.O. Box 651366, Salt Lake City, UT 84165-1366
•
Acupuncture•
Dermatologist•
Orthopedic Shoes•
Acne medications*•
Air Purification Equipment•
Fertility Treatment•
Osteopath•
Allergy & sinus•
Allergist•
Hearing Exams•
Oxygen•
Antibiotic products*•
Ambulance•
Hearing Aids & Batteries•
Physical Examination•
Anti-itch & insect bite*•
Arches & Orthotic Inserts•
Homeopath•
Physician•
Cold sore remedies*•
Blood & Metabolism Tests•
Hospital Beds•
Prescription Drugs•
Cough, cold & flu*•
Body Scans•
Hospital Services•
Prosthetics•
Digestive aids*•
Cardiograms•
Immunization•
Psychiatrist or Psychologist•
First aid burn remedies*•
Chiropractor•
In Vitro Fertilization•
Service Animals•
Motion sickness*•
Christian Science Practitioner•
Insulin•
Sterilization/Sterilization•
Oral remedies or treatments*•
Contraceptive Devices•
Laboratory Fees•
Syringes•
Pain relief*•
Copays•
Nebulizers•
Transplants (including organ•
Sleep aids & sedatives*•
Crutches, Walkers, Wheel Chairs•
OB/GYN Exams•
X-Rays•
Smoking deterrents*•
Deductibles•
Optometrist*OTC Medicated expenses require a prescription
•
Contact lens solution•
Eyeglasses and Contact Lenses•
Prescription Sunglasses•
Eye Exams•
Laser Eye Surgeries•
Radial Keratotomy•
Dental X-Rays•
Extractions and Fillings•
Periodontal Services•
Dentures and Bridges•
Oral Surgery•
Retainers•
Exams and Teeth Cleaning•
Orthodontia•
Cologne•
Face creams•
Prepayments•
Controlled substances violating federal law•
Feminine hygiene products (tampons, etc.)•
Prescription drug discount programs•
Cosmetic procedures•
Fluoride rinses•
Shampoos•
Cosmetics•
Insurance premiums from an FSA•
Skin moisturizers•
Dental floss•
Laser hair removal•
Soaps•
Deodorant•
Makeup•
Tanning salons and equipment•
Diet foods•
Marijuana•
Teeth whitening•
Ear piercing•
Moisturizers•
Toothbrushes•
Electrolysis or hair removal•
Mouthwash•
ToothpasteCaf (10/2012)
Sample Eligible Expense Sheet
Items that are generally not eligible but may qualify if prescribed by a Medical Practitioner
Medical Expenses
Vision Expenses
Dental Expenses
Ineligible Items
If you have a question on an expense that is not on this list please contact ABG-Rocky Mountain. Alliance Benefit Group-Rocky Mountain (801)486-3087
Mail to: P.O. Box 651366, Salt Lake City, UT 84165-1366 Fax: (801)483-0798