Get Debit Card Substantiation Form

The Debit Card Substantiation Form is essential for validating transactions made with your Flexible Spending Account (FSA) debit card. This guide will provide you with clear, step-by-step instructions to ensure you complete the form correctly and efficiently.

Follow the steps to submit your Debit Card Substantiation Form online.

1. Press the ‘Get Form’ button to access the Debit Card Substantiation Form and open it in your document editor.
2. Complete the employee information section by providing your name, company name, the last four digits of your Social Security number, telephone number, and email address.
3. Gather and enclose copies of all itemized bills, receipts, or Explanation of Benefits (EOB) from your provider. Ensure these documents are submitted within the specified time frames: 45 days for medical transactions and 15 days for dependent care transactions.
4. For orthodontia claims, include a copy of the Monthly Orthodontia Claim Form or your orthodontia services contract, ensuring it provides the necessary details such as the provider's name, services rendered, start date, total months, and an itemized list of fees.
5. Verify that the bills and receipts contain the required information: date of service, provider’s name, description of service, and cost of service.
6. Fax the completed form along with all supporting documents to the number provided. Alternatively, if you prefer, you can mail the substantiation to the specified address.
7. Retain a copy of the form and all submitted documents for your records. Remember to use only blue or black ink to mark FSA items on receipts.
8. If you have additional claims, complete more Debit Card Substantiation Forms as needed.
9. Upon completion, you can save changes, download, print, or share the form, ensuring you follow the proper documentation procedures.

Get started now by filling out your Debit Card Substantiation Form online.