INSTRUCTIONS: ALABAMA REQUEST FOR REIMBURSEMENT PREFERRED HEALTH FSA/HRA (Form CL-472)

In Alabama, state employees enrolled with BlueCross BlueShield use a form CL-472 to request a reimbursement for eligible health services. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 1: The employee should enter their signature and the date at the top of the form where indicated.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 2: Section 1 concerns the employee. Your first name, middle initial and last name in the first three blank boxes.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 3: In the next three blank boxes, enter the month, date and year of your birth.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 4: Enter your preferred blue account number prefix in the next blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 5: Enter your preferred blue account number contract number in the blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 6: Enter your company name in the next blank box.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 7: Enter your work and home phone numbers in the next two blank boxes, including the area codes.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 8: Section 2 concerns the type of reimbursement being sought. Indicate whether the service was medical, vision, dental, orthodontics, RX/OTC or other by filling in the oval next to the appropriate statement.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 9: In the first two blank boxes, enter the patient's first and last names.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 10: Indicate whether the patient is self, your spouse or a dependent by filling in the appropriate oval.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 11: Indicate whether the patient is covered by insurance by filling in the appropriate oval.

Alabama Request For Reimbursement Preferred Health FSA/HRA CL-472 Step 12: Provide all other information requested about the patient. You may document up to five patients on one form. Provide the amount requested for reimbursement for each service and the total at the bottom of the page.