Get Flexible Spending Claim Form - Steve Elrod & Associates

Filling out the Flexible Spending Claim Form is an essential step in claiming medical or dependent care expenses. This guide will provide you with detailed instructions to complete the form accurately and efficiently.

Follow the steps to successfully complete your claim form.

1. Press the ‘Get Form’ button to access the Flexible Spending Claim Form and open it in your preferred document editor.
2. Begin by entering your employer's name in the designated field at the top of the form. This information is essential for processing your claim.
3. Fill in your personal details, including your last name, first name, middle initial, and social security number in the respective fields.
4. Provide your address, including street, city, state, and zip code. If you have recently moved, check the box indicating that this is a new address.
5. Enter your phone number in the phone field. Ensure that the format is correct to facilitate communication regarding your claim.
6. For medical expense claims, fill out the section with details of each service. Enter the date of service, patient's name, their social security number, relationship to you, a description of the service, name of the provider, and the claimed amount for each expense.
7. Total the claim amount at the bottom of the medical expense claim section.
8. For dependent care claims, provide the date of service, dependent's name, age, the name of the dependent care provider, their address, and their tax ID or social security number.
9. Total the claim amount at the bottom of the dependent care claims section as well.
10. Complete the employee’s certification section by signing and dating the form, confirming that the expenses are eligible for reimbursement and have not been claimed elsewhere.
11. Attach copies of the receipts for the claimed expenses to the form before submission.
12. Finally, save your changes, then download, print, or share the filled form as needed. For faster reimbursement, you may consider faxing or mailing the completed form to the provided address.

Start completing your Flexible Spending Claim Form online today for a smoother reimbursement process.