Get Fsa Reimbursement Bformb - Healthtrust - Orcsd

This guide provides comprehensive instructions on how to accurately complete the FSA Reimbursement Form - HealthTrust - Orcsd online. We aim to help users navigate each section of the form with clarity and confidence.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to access the form and open it in your preferred text editor.
2. Fill out the employee information section. Include your employer's name, plan year, and your personal details such as your name, address, city, state, and zip code.
3. In Part 1, Healthcare FSA Expenses, provide the names of individuals receiving services, their relationship to you, the date services were provided, a description of the services, and the total amount charged by the provider.
4. In Part 2, Dependent Care Reimbursement Account Expenses, enter the dependent's name, date of birth, date services were provided, provider name, and the total amount charged, including the provider's Tax ID number.
5. Calculate the subtotals for healthcare expenses and dependent care expenses, and enter the total amount of reimbursement requested at the bottom of the form.
6. You may opt to request that your dependent care provider complete the Dependent Care Provider's Certification of Services Rendered section, or alternatively, attach a receipt that includes all required information.
7. Complete the Employee Certification section by signing and dating the form. Ensure all entries are true and complete to avoid delays.
8. Review the entire form for accuracy, then save your changes. You can download, print, or share the completed form as needed.
9. Submit the form via mail or fax to HealthTrust along with all necessary supporting documents.

Start completing your FSA Reimbursement Form online today for an efficient reimbursement process.