Follow the steps to complete your form accurately.

1. Click the ‘Get Form’ button to access the health care Fsa reimbursement form. This will open the form in your preferred editor.
2. Begin filling out your personal information. This includes the employee name, employer’s name, division (if applicable), Social Security number or ID, daytime phone number, email address (optional), and complete address including city, state, and zip code.
3. Individually list each receipt on the claim form. Ensure that you complete the entries for each receipt with required details including dates of service, patient name, relationship to participant, name of provider or pharmacy, description of service or medicine, and the reimbursement requested.
4. Provide the total reimbursement requested for each expense. Ensure that you do not aggregate receipts; each one must be documented separately on the form.
5. Review and complete the certification section carefully. By signing, you confirm that the submitted medical care expenses are valid, and you acknowledge your responsibilities regarding tax reporting and adherence to IRS guidelines.
6. After completing the form, assemble any required supporting documentation. Make sure to attach copies of your Insurance Explanation of Benefits or itemized statements for each claim.
7. Submit your completed form and documentation via fax or mail. The preferred method for over-the-counter claims is to fax them to 410-771-9487. If mailing, send it to the address provided for Crawford Advisors, LLC.
8. Finally, keep a copy of this form and all original receipts for your records. This will help you track your claims and provide documentation if needed.

Start completing your Crawford Advisors Fsa form online now to ensure timely reimbursement of your health care expenses.