instructions
BAS CLAIM FORM
Mail or Fax To:
BAS
P.O. Box 62407
King of Prussia, PA 19406
FAX: 1.888.265.2144 		MyEnroll.com
Please type or print legibly.     * Required Fields
 EMPLOYEE'S NAME
 * FULL NAME 
 * SOC. SEC. #       * EMPLOYER 
WORK PH # 
WORK EXT 
HOME PH # 
 * EMPLOYEE'S STREET ADDRESS * CITY * STATE    * ZIP
 Please complete this Dependent Section only if you are submitting claims for a dependent. Please note: A separate claim form must be used for each dependent's claims.
 DEPENDENT'S NAME
 FULL NAME 
 DATE OF BIRTH       SOC. SEC. # 
 DEPENDENT'S STATUS
HANDICAPPED
FULL-TIME STUDENT
CLAIM EXPENSE INFORMATION
CLAIM YEAR
* DATES OF SERVICE (MM/DD)
FROM TO
* CARE PROVIDER'S NAME DESCRIPTION
OF SERVICES
RECEIVED		 CLAIM
AMOUNT

X
EMPLOYEE'S SIGNATURE DATE
*
© 2002- Benefit Allocation Systems, LLC
Form BAS claim_form_med_bw Ed. 03/2016