Fillable Printable EBPA Confidential Reimbursement FAX Cover Sheet

EBPA Confidential Reimbursement FAX Cover Sheet

EBPA Reimbursement Department 1-888-678-3457

The material in this FAX is confidential. Please be sure it is received by the intended recipient as soon as possible.

EBPA Reimbursement FAX Cover Page

To: EBPA Reimbursement Department FAX #: 1-603-773-4415

Participant’s Name:

___________________________

Employer Name:

__________________

DATE:

Number of pages

Including this cover page: ____________

Participant’s Contact Information: Telephone Number or Email Address

___________________________________________________

RECOMMENDED

You may obtain copies of this FAX Cover Sheet at: http://www.ebpabenefits.com/members

Important Claim/Substantiation Submission Information

Please check the box that applies

 New Claim Submission

To ensure there are no delays in processing your claim(s), you are required to complete, sign and submit an

"FSA Reimbursement Claim Form" for all new reimbursement claims.

(Found on your FSA webpage at www.ebpabenefits.com under Member Access)

 Substantiation / Documentation Submission

Please remember to include a copy of the "Substantiation Letter" or "Denial Letter" when submitting your

response and/or documentation. Please do not submit a new Reimbursement Form.

MESSAGE:

_____________________________________________________________________________________

__________________