Get Fsa Reimbursement Request Form - Delranschools

Filling out the FSA reimbursement request form is a crucial step in managing your flexible spending account effectively. This guide provides clear, step-by-step instructions to ensure you complete the form accurately, facilitating a smooth and timely reimbursement process.

Follow the steps to complete your reimbursement request form

1. Click ‘Get Form’ button to access the form and open it in the appropriate editor.
2. Enter the current date at the top of the form. It's important to keep this date accurate as it may be relevant when processing your request.
3. Fill in the number of pages you are submitting. This helps keep track of your submitted documents.
4. Complete the claim information section by entering the total amount of reimbursement you are requesting. Make sure this figure reflects the eligible expenses incurred.
5. Sign and date the form certifying that all listed expenses have not been reimbursed from any other source and comply with IRS guidelines.
6. In the participant information section, provide your social security number (optional), employer's name, and your full name, including the first name, middle initial, and last name.
7. Enter your email address, current address (including street address, floor or apartment number, city, state, and zip code), and both daytime and evening phone numbers for contact purposes.
8. List each patient and service separately in the reimbursement claim section. Include the date services were provided, the patient’s name, the name of the provider, the type of service provided, and the net amount.
9. Attach any required supporting documentation, including itemized statements from providers and any relevant Explanation of Benefits from your insurance. Ensure these documents clearly outline the date of service, description of service, and total cost.
10. Once you have completed the form and attached all necessary documentation, save changes to your document. You may also choose to download, print, or share the form as needed.

Complete your FSA Reimbursement Request Form online today for efficient processing!