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  • Hcr/dcr Reimbursement Form - Flexible Spending Account ...

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Sec. 125 HCR & DCR Reimbursement Request IRS Section 125 Health Care Reimbursement (HCR) Account & Dependent Care Reimbursement (DCR) Account I. Employee Information Your Employer ( ) Day time telephone.

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What Are My FSA Eligible Expenses? The IRS determines which expenses are eligible for reimbursement. Eligible expenses include health plan co-payments, dental work and orthodontia, eyeglasses and contact lenses, and prescriptions. This type of FSA is offered by most employers.

Toiletries are not eligible for reimbursement with a flexible spending account (FSA), health savings account (HSA), health reimbursement arrangement (HRA), limited-purpose flexible spending account (LPFSA) or a dependent care flexible spending account (DCFSA). What are toiletries?

Health Care Reimbursement Accounts have No Annual Limits Unlike a Health Savings Account (HSA) or a Flexible Spending Accounts (FSA), there is no limit to the amount of money an employer can contribute to an employee's health care reimbursement account.

Required Documentation: Itemized statement from the provider with a clear description of service provided, name of the patient, date of service, the amount paid for service, and name of the provider. A signed statement indicating there is no insurance coverage for the service provided.

Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, , and medical devices. You decide how much to put in an FSA, up to a limit set by your employer. You aren't taxed on this money.

An itemized receipt with the five pieces of information is compliant. They need the date(s) of service, dependent's name, provider's name, type of service, and the total dollar amount paid for the services.

With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you'll get reimbursed for your costs. Ask your employer about how to use your specific FSA.

What types of expenses are not eligible for reimbursement with an FSA? Skin or teeth bleaching/whitening; Health club dues; Hair transplants; Electrolysis; Cosmetic surgery or treatments of any kind; and, Contract fees for maintenance/replacement of contact lenses or eyeglasses.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232