Get Priorityfsa Flexible Spending Arrangement Withdrawal Request Form. Fsa Request Form

Completing the PriorityFSA Flexible Spending Arrangement Withdrawal Request Form is essential for users seeking reimbursement for eligible health care or dependent care expenses. This guide will provide you with clear, step-by-step instructions to ensure you fill out the form correctly and efficiently.

Follow the steps to complete your withdrawal request form.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In Section 1: Employee Information, input your full name, date of birth, address, contact phone numbers, contract number, employer name, and group number. Ensure every field is accurately filled out to avoid delays.
3. For Section 2: Health Care Expenses, provide the patient's name and select the relevant expense categories (Dental, Orthodontia, Medical, Over-the-counter). Specify the relationship to the employee, the dates of service, and the total amount. Remember to attach supporting documentation as required.
4. If applicable, fill out Section 3: Dependent Care Expenses by entering the dependent care provider's name and address, your dependent's full name and relationship to you, their tax ID or SSN, and the dates of service along with the total amount. Make sure to attach a proper receipt.
5. In Section 4: Employee’s Certification, read the certification statement thoroughly. Sign and date the form to confirm the accuracy of your claims.
6. Review all sections to ensure completeness and accuracy, then save your changes.
7. Finally, send the completed form and the relevant receipts by fax or mail. Keep copies of everything for your records.

Start filling out your PriorityFSA withdrawal request form online now to get your reimbursements!