Get Fsa Withdrawal Request Form - Priority Health

Completing the FSA Withdrawal Request Form is essential for users seeking reimbursement for eligible expenses under the Flexible Spending Arrangement with Priority Health. This guide will provide clear and supportive instructions for successfully filling out the form online.

Follow the steps to fill out the FSA withdrawal request form online

1. Press the ‘Get Form’ button to access the FSA Withdrawal Request Form and open it in your preferred document editor.
2. In Section 1, enter your employee information, including your name, date of birth, telephone number, address, employer name, contract number, group number, and zip code.
3. In Section 2, fill in the details about your health care expenses. Specify the relationship to the employee, patient name, dates of service, expense categories (e.g., dental, vision), and the total amount.
4. Make sure to attach supporting documentation such as the Explanation of Benefits or itemized receipts as required according to the expense categories.
5. In Section 3, if you are claiming dependent care expenses, provide details such as the dependent care provider's name, dependent’s full name, address, tax ID or SSN, dates of service, and the total amount.
6. Attach the necessary receipts for dependent care as outlined, ensuring they include the provider's contact information and service dates.
7. Proceed to Section 4 where you will certify that the expenses you are claiming are eligible for reimbursement. Be sure to sign and date the form to confirm your certification.
8. After completing the form, review all entries for accuracy, and then save any changes. You may choose to download, print, or share the completed form as needed.

Begin filling out your FSA Withdrawal Request Form online today!