Get Health Care Spending Account Form

Filling out the Health Care Spending Account Form online can be a straightforward process with proper guidance. This guide provides clear instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the online form successfully.

1. Click ‘Get Form’ button to access the Health Care Spending Account Form and open it in your preferred online document editor.
2. Fill in your employee information, including your limited FSA identification number, last name, first name, middle initial, daytime telephone number, street address, city, state, and zip code.
3. Provide the employer information by entering your employer's name and the limited FSA control number, if it is not already pre-printed on the form.
4. For expense information, list each patient separately, including their first name, date of birth, relationship to you as the employee, and dates of service. Enter the total amount submitted for each expense.
5. If you are submitting claims for orthodontia expenses, ensure to read the relevant section on the back of the form before detailing the required information for each orthodontia-related expense.
6. Indicate whether you or any family members for whom you are requesting reimbursement are eligible for benefits under any other medical plans by checking 'Yes' or 'No.' If 'Yes,' include copies of all explanation of benefits (EOBs).
7. Complete the employee certification section by signing and dating the form. This is required to prevent claim payment delays.
8. Once you have filled out all sections, review the form for accuracy. Save your changes to ensure your information is not lost.
9. Finally, download, print, or share the completed form as required, and retain a copy for your records.

Get started now and complete your Health Care Spending Account Form online!