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The maximum time period provided on the form cannot exceed one year from the date of the doctor s signature. Doctor s Statement Form The Internal Revenue Service requires a doctor s statement be provided for certain healthcare expenses in order to be reimbursed from your healthcare Flexible Spending Account FSA or Health Reimbursement Arrangement HRA. The doctor s statement must indicate the specific medical disorder the specific treatment needed and how this treatment will alleviate the medical condition. This form will assist you and your healthcare provider in providing the information we need in order to process your reimbursement request. Please be sure to print the requested information clearly on all documentation submitted. Please note If your treatment extends beyond the time period listed by the provider you will need to submit a new doctor s statement form upon expiration of the initial treatment dates. Your provider can also write a letter on his or her letterhead as long as the letter includes all the information on this form* In addition to the information from your provider certain expenses require a but for statement from the employee noting that the expense would not have been purchased had it not been for the provider s recommended treatment plan* A but for certification section is also included in the form which should be completed by you to ensure all required information is on file. For fast and accurate processing of your reimbursement request please make sure to include this itemized receipt or other documentation* The reimbursement request claim form can be found on the selfservice employee web site provided by your employer. If treatment extends beyond one year a new form will be required at the end of each one-year period. Send the completed form with the signature of the healthcare provider and participant to FAX Spending Account Management 1-866-643-2219 Toll-free MAIL ADP Spending Accounts P. O. Box 34700 Louisville KY 40232 Submission of this form is not a guarantee that the expense will be reimbursed* continued Page 1 of 2 Please print clearly with blue of black ink or type. Signature sections must be signed* Employee name Alternate ID/SSN E-mail Phone Employer Patient name Diagnosis/Diagnosis code CPT code must be explained in detail How will the recommended treatment alleviate the diagnosis or symptoms Date treatment began How long is the treatment required Additional comments Provider name and title Provider address Provider phone Provider license and state Provider signature Date Employee certification By signing below I certify that this expense would not have been incurred but for the recommendation of the healthcare provider. Your provider can also write a letter on his or her letterhead as long as the letter includes all the information on this form* In addition to the information from your provider certain expenses require a but for statement from the employee noting that the expense would not have been purchased had it not been for the provider s recommended treatment plan* A but for certification section is also included in the form which should be completed by you to ensure all required information is on file. For fast and accurate processing of your reimbursement request please make sure to include this itemized receipt or other documentation* The reimbursement request claim form can be found on the selfservice employee web site provided by your employer. .

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