Get Fsa Claim Form

Filling out the Flexible Spending Account (FSA) Claim Form online is a straightforward process that can help you efficiently manage your medical expenses. This guide provides clear, step-by-step instructions to assist you through each section of the form.

Follow the steps to complete your FSA Claim Form online.

1. Click ‘Get Form’ button to obtain the FSA Claim Form and open it in your editor.
2. In Part 1, enter your employee information. Fill in your name, employee identification number, date of birth, and address accurately.
3. Move to Part 2 for health care expenses. Provide the patient’s name and daytime telephone number. List each expense separately with the date(s) of service, type of services, including medical, vision, dental, and hearing.
4. If you have expenses that were partially covered by insurance, attach your Explanation of Benefits (EOB) statement along with itemized bills to ensure the FSA Customer Service Center understands the services provided.
5. For expenses not covered by insurance, include the provider's name and address, dates of service, dollar amount charged, and mark ‘Not Covered by Insurance’ on the receipt.
6. Complete Part 3 for dependent care expenses by entering the dependent's name and service details. Ensure the receipt shows the date(s), type, and cost of the service and that the dependent care provider certifies the services rendered.
7. In the certification section, sign and date the form. Your signature confirms the truth of the information provided and that the expenses have not been reimbursed elsewhere.
8. Review your completed form for accuracy. Make copies of the form and documentation for your records.
9. Finally, save your changes, and download or print the form to submit it by mail or fax to the provided address.

Complete your FSA Claim Form online today and ensure you receive reimbursement for your eligible expenses.