Get Tri-star Fsa Claim Form

Filling out your Tri-Star FSA Claim Form online is a straightforward process that enables users to efficiently manage their Flexible Spending Account claims. By following this guide, you'll learn how to complete each section of the form with clarity and accuracy.

Follow the steps to complete the Tri-Star FSA Claim Form online

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. In Part 1, fill in your personal information. This includes your Social Security Number or Account Number, last name, first name, middle name or initial, and address details such as street, city, state code, zip code, phone number, and email address. Only complete the address, phone number, and email sections if these have changed recently.
3. Proceed to Part 2 if you are filing for Dependent Care FSA claims. Here, you will need to check the box if your claim substantiates an FSA Debit Card transaction. Provide the dependent's name, age, service from and through dates, provider name, provider tax identification number, and the claimed amount. Then, total the claimed amount for dependent care services.
4. If you do not have receipt attachments for the Dependent Care expenses, complete the Dependent Care Provider Certification. Here, the provider must enter their name and provide an authorized signature to confirm the information listed in Part 2 is correct.
5. In Part 3, for Health Care FSA claims, check the box if this claim is also for an FSA Debit Card transaction. Input the patient’s name, service dates, description of service, provider name, and the claimed amount. Again, total the claimed amount for health care services.
6. In Part 4, you need to acknowledge and sign the statement certifying that all services and expenses claimed were received by you or an eligible dependent. Confirm that these expenses have not been reimbursed through any other health plan and that you understand your responsibilities regarding the accuracy of the information provided.
7. Once you have filled out all sections of the form, review it for completeness and accuracy. Finally, save your changes, and download or print the form as needed. You can also share the completed form as required.

Start completing your documents online today for efficient management of your claims!