Get Flexible Spending Account Claim Form - Midamerica

Filling out the FLEXIBLE SPENDING ACCOUNT CLAIM FORM is essential for anyone seeking reimbursement for eligible healthcare expenses. This guide will walk you through each section of the form to ensure you complete it accurately and submit it successfully.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, fill out all personal information completely. This includes your employer's name, social security number, your name, address, daytime phone number, email, city, state, zip code, date of birth, and date you were last employed. If this is a permanent address change, check the provided box.
3. In Section 2, you must attach supporting documentation for all claims incurred by you, your spouse, or other eligible dependents. List your recurring expenses in the provided table, ensuring you include the date of expense, name of service provider, name of covered participant or dependent, service provided, and the amount you are requesting for reimbursement. Remember that reimbursable expenses must total at least $100 before submission.
4. If your claim is on behalf of a deceased participant, complete Section 3 by providing the name and address for check mailing along with a copy of the death certificate.
5. In Section 4, you must sign and date the claim form to request payment from the reimbursement account. Ensure that your statements on the form are true and complete. Without a signature, the claim cannot be processed.
6. After completing all the sections, review for accuracy. Save your changes, then download or print the form and any attached documentation.
7. Submit the completed form and attachments to MidAmerica Administrative & Retirement Solutions, Inc., ensuring it is sent to the appropriate department to facilitate prompt processing.

Begin your claim process by filling out the FLEXIBLE SPENDING ACCOUNT CLAIM FORM online today!