Get Fsa Claim Form - Arcadia Benefits Group

Filling out the Flexible Spending Account (FSA) Claim Form is essential for users seeking reimbursements for eligible expenses. This guide provides a clear, step-by-step approach to successfully complete the form online, ensuring you follow the necessary guidelines.

Follow the steps to accurately complete your FSA Claim Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the employer's name at the top of the form. This identifies your workplace.
3. Enter your full name (last name, first name, middle initial) along with your Social Security number. This personal information is crucial for processing.
4. Provide your home address, including number/street, city, state, and zip code. This ensures that communication regarding your claim reaches you.
5. Include your daytime telephone number and email address for further correspondence.
6. Indicate if this is a new address by checking the designated box. This helps in maintaining up-to-date records.
7. For direct deposit, fill in the banking institution’s name, account type (checking or savings), routing number, and account number for efficient and secure reimbursement.
8. Under the health FSA section, list the date of service, patient’s name and relationship, description of service, amount of reimbursement, and provider of service.
9. For dependent care FSA, attach a receipt or statement from your provider with the required dates of service and fill in the necessary details for each service rendered.
10. Record the total expenses for both health and dependent care sections, ensuring accuracy for total reimbursement.
11. Sign and date the form at the bottom, certifying that the information provided is correct and that you have not claimed these expenses elsewhere.
12. Finally, save any changes you've made, and ensure the form is downloaded, printed, or shared as necessary.

Complete your FSA Claim Form online efficiently today and ensure you receive your reimbursements promptly.