Get Health Fsa Claim Formpdf - Ucnet - University Of California - Hr Uci

Filling out the Health Flexible Spending Account (FSA) Claim Form can seem daunting, but with a clear guide, users can efficiently navigate the process. This document provides a comprehensive overview of each section of the form—ensuring that individuals can submit their claims accurately and promptly.

Follow the steps to complete the Health FSA Claim Form online.

1. Press the ‘Get Form’ button to access the Health FSA Claim Form and open it in your preferred editor.
2. In the designated section, enter your CONEXIS account number and, if necessary, your Social Security number or your first and last name.
3. Provide your email address if it is not already on file.
4. Select the appropriate category of expenses from the options provided, including Medical, Vision, Dental, Orthodontic, Prescription, or Over-the-Counter.
5. For each service, enter the patient's first name, the date of service, and the requested amount in the specified fields.
6. If applicable, itemize any travel or mileage reimbursement requests on a separate page, including the date, miles traveled, and type of service.
7. Attach all supporting documentation that indicates provider name, date of service, description of service, and the patient responsibility amount.
8. Complete the Employee Certification section by verifying that all the statements are accurate and relevant to your claim.
9. Sign and date the form to confirm your submission.
10. Finally, save your changes, download the form, or print it for submission.

Complete your Health FSA Claim Form online today for a smooth reimbursement process!