Get Flexible Spending Account Claim Form - Abc Benefit Solutions

Filling out the Flexible Spending Account Claim Form is essential for users seeking reimbursement for eligible expenses. This guide will provide clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your claim form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In section I, enter your employer's name and the plan year ending date.
3. In section II, provide the participant's name and social security number.
4. Section III requires details for medical expenses and over-the-counter medication claims. Fill in the patient name, relationship to the employee, physician's or provider's name, date of service, description of service or medication, and specify if insurance covers the service. Ensure to attach the necessary documentation.
5. In the 'Total Medical and OTC Claims' section, indicate the total amount incurred for medical expenses.
6. For dependent care expense claims in section IV, include the dependent's name, your relationship to them, provider details, dates of service, and amounts incurred. Attach required documentation.
7. In section V, complete the individual plan premium reimbursement section by entering the insurance carrier's information, coverage dates, and amounts incurred. Ensure you attach the documentation for premiums.
8. Section VI is the statement of the participant. Read the certification carefully, then sign and date the form. Include your daytime phone number.
9. After thorough review, save your changes, and choose to download or print the form. Submit the completed form with all attachments to your benefits coordinator or the provided postal address.

Get started today to fill out your Flexible Spending Account Claim Form online and ensure a seamless reimbursement experience.