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Health Care Eligible Expenses 800.989.8776 p: 248.543.2644 f:248.543.2296 (The United Methodist Church Michigan Conference)

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Flexible Spending
Account Claim Form
1423 E. 11 Mile Road, Royal Oak, MI 48067
800.989.8776 • p: 248.543.2644 • f:248.543.2296
www.HRPro.biz
FSA Employee Claim Form HRPro Revised 9/22/2017
YOU MAY USE THIS FORM OR FILE CLAIMS ONLINE AT WWW.HRPRO.BIZ
This form is to be used for non-debit card claims only (SEE ACCOUNT LOGIN INSTRUCTIONS ON THE BACK OF THIS FORM)
Employer Name:
Employee Last Name: First Name: Last 4 digits of SSN
Street Address: City: State: Zip:
Daytime Phone: Email Address (For claim correspondence only):
Health Care Eligible Expenses
Description of Eligible Expense
Date of
Expense
Total Cost
Amount Paid by
Any Plan
Your Cost
(Claim Amount)
Expenses for:
Name (And if Dependent, Relationship & DOB)
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
TOTAL $
Dependent Care Eligible Expenses
Care Provider Name
Fed ID# or SSN of
Care Provider
Date of
Care From
Date of
Care To
Total Amount
Expenses for:
Name, Relationship & DOB
$
$
$
$
$
$
$
$
TOTAL $
I certify that these expenses were incurred by myself and/or my eligible dependents. I further certify that these expenses are not reimbursable under
any other plan, including a plan of another employer that covers me, my spouse or another member of my family.
I understand that I cannot use expenses reimbursed through this account as deductions when filing my individual income tax return. I understand
that if I do not provide required documentation, I will not be reimbursed. I authorize my employer to deduct the total amount requested from my
account in accordance with the terms and provisions of the Flexible Spending Account plan. If I receive reimbursement for health care expenses that
are not eligible, I agree on demand to indemnify and reimburse my employer for any liability I may incur for failure to withhold income tax or Social
Security tax up to the amount of additional tax actually owed by me.
Employee Signature:
Attach copies of bills or receipts and return to:
HRPro
1423 East 11 Mile, Royal Oak, MI 48067
Tel: (248) 543-2644 Fax: (248) 543-2296
Email: claims@hrpro.biz
Date:
Flexible Spending
Account Claim Form
1423 E. 11 Mile Road, Royal Oak, MI 48067
800.989.8776 • p: 248.543.2644 • f:248.543.2296
www.HRPro.biz
FSA Employee Claim Form HRPro Revised 9/22/2017
Instructions for Filing a Claim
1. Please type or print all information clearly and submit claim form to HRPro via mail, fax or email. Keep a copy of the claim
form and receipts for your records. You may call HRPro at (248) 543-2644 with any questions regarding your claim.
2. Attach copies of itemized bills, EOBs or receipts to the claim form (You keep the originals). Canceled checks are not
accepted.
3. You may only submit expenses incurred by you or your eligible dependents (as defined by the Internal Revenue Service).
4. Claims will be accepted and processed according to the schedule set forth by your employer.
5. Remember, disbursements from your spending accounts are made on a pre-tax basis. When filing your annual income tax
return, do not declare reimbursements as income and do not take any expenses you have been reimbursed for as a
deduction.
Online Access to Your Account
Allows you to:
File claims online
Check account balance and claim history
Review outstanding receipt requirements
View plan information
Download forms
How to Login:
1. Log into www.hrpro.biz and click on “Login”
under Participant Resources or click the
“Login” button on top of page.
2. Login using the following:
Username: First initial (cap), full last name
(lowercase) and the last 4 digits of your
SSN.
Example:
John Smith 123-45-6789 would login as:
Jsmith6789
If this is your first time logging onto the
system, use Password1 as your password.
You will be prompted immediately to create
a new, unique password before entering
the participant portal.
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Health Care Eligible Expenses 800.989.8776 p: 248.543.2644 f:248.543.2296 (The United Methodist Church Michigan Conference)

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Completed 23 August 2021

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