Get Dfb Tpa Fsa Ee Reimbursement Form

Filling out the DFB TPA FSA EE Reimbursement Form online can streamline the reimbursement process for unreimbursed medical expenses. This guide will provide clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your reimbursement form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editing tool.
2. Fill in personal data in the designated section, including the plan year, company name, your name, home phone number, and complete address including street, apartment number, city, state, and zip code.
3. In the unreimbursed medical benefits section, enter the date when medical care was provided. Then, provide the name of the medical provider and a brief description of the general medical expense, including any relevant medical conditions for over-the-counter items.
4. Input the name of the patient who received the medical service and their relationship to you.
5. Enter the amount that is your responsibility for the medical expenses. This should be the total you are claiming for reimbursement.
6. Total the medical amount requested and ensure you have arranged your documentation in the order listed above before submitting the claim.
7. Review the terms and conditions section, ensuring you understand that all expenses were incurred while you were covered under your employer's Health FSA and that they haven't been reimbursed from any other source.
8. Sign and date the form to certify the accuracy of the information provided and state your understanding of the responsibilities outlined.
9. Submit your completed claim form by fax or email, as provided in the instructions, or mail it to the specified address for DFB TPA FSA Claims.

Start completing your DFB TPA FSA EE Reimbursement Form online today for a hassle-free reimbursement experience.