Get VitaFlex Medical Expense Claim Form

Employers may make contributions to your FSA, but they aren't required to. With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you'll get reimbursed for your costs.

That's why your FSA administrator may prompt you for receipts, explanation of benefits (EOBs), or other necessary documentation. When this occurs, it's because auto-substantiation could not take place and additional information is needed in order to comply with IRS FSA rules.

Remember, to be accepted for a claim, you'll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).

We can provide an itemized receipt that you can submit to your FSA administrator for reimbursement. On the form you submit for reimbursement from your FSA, you'll need to include personal details and information about the product or service you receive, any amounts owed and the date of the service provided.

Eligible expenses include (but are not limited to) co-payments, prescriptions, co-insurance amounts, dental work (non-cosmetic), or contact lenses. For a more complete list of eligible expenses, you may refer to the Vita Flex Eligible Claims Guide.

Submit Your Claim in One of These Ways Once you have logged into your account, click Submit Receipt or Claim and select your Reimbursement Option. Follow the step-by-step instructions. Upload digital copies of your itemized receipts (and other documentation if needed).