Get National Benefit Services Claim Form

Filing the National Benefit Services Claim Form online can streamline the reimbursement process for your flexible spending account. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your personal information. Fill in your name, company name, and address, including city, state, and zip code, along with your phone number and social security number. Ensure all entries are clear and accurate.
3. Indicate if there has been an address change by selecting 'Yes' or 'No.' This will help ensure timely communication regarding your claim.
4. For dependent care expenses, fill in the date of service (MM/DD/YYYY), the tax ID or social security number of the service provider, the dependent's name, their age, and the amount for each expense. List each expense on a new line.
5. Proceed to the health care expenses section. Again, detail the date of service, and select the type of service from the options provided, such as office visit or dental. Fill in the name of the person receiving the service and the corresponding amount, ensuring each entry is on a new line.
6. Add up all entries in the total sections for both dependent care and health care expenses. It is crucial that you ensure the totals are correct to avoid delays in processing.
7. Sign the form to attest that the details you provided are complete and true. This includes authorizing the release of any necessary medical information. Date your signature.
8. Finally, review the completed form for any errors or omissions. Save your changes, then download or print the form. Attach copies of supporting documentation such as receipts or Explanation of Benefits (EOB).
9. Submit your claim form and receipts via mail, fax, or email as per the instructions provided at the end of the form.

Start filling out your claim form online today to ensure timely reimbursement for your qualified expenses.