Get 2013 Flex Plan Fsa Claim For Reimbursement - My Triquint Benefits

Filing a claim for reimbursement through the 2013 Flex Plan FSA Claim Form can be straightforward with the right guidance. This guide will walk you through each section of the form, ensuring you have the information needed for a successful submission.

Follow the steps to complete your claim form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Complete Section I – Employee Information by entering your last name, first name, middle initial, day phone, employee SSN, and address including city, state, and zip code. Be sure to include your email address for communication purposes.
3. If there are any updates to your address, check the 'Address Change' box.
4. For claims related to day care expenses, complete Section II. Enter the start and end date of the service, the provider's name along with their tax ID or social security number, the name and age of the dependent, and the total cost of the day care services.
5. Attach the required third-party documentation for day care claims, ensuring it shows the date(s) of service, cost, dependent's name, and provider's information. Do not use canceled checks or bank card receipts.
6. For health care claims, move to Section III. Provide details such as the service dates, type of service, name of the provider and confirm if you used your Benny Card.
7. Itemize all expenses in Section III to prevent delays in reimbursement. Attach proper third-party documentation, ensuring it reflects the dates and types of services received.
8. Finalize your claim by completing Section IV. Sign the claim form, confirming that the statements made are true and complete. Specify the date of your signature.
9. Once completed, submit your claim form by choosing one submission method: fax, email, or mail. Only use one method for each claim submission to maintain clarity.
10. After submission, you can track the status of your claim through the online portal. Ensure that your claims are submitted at least two full business days prior to the scheduled reimbursement date.
11. You may save changes, download, print, or share the form as needed.

Complete your claim form online today to ensure timely reimbursement for your health and day care expenses.