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The Ceridian FSA Reimbursement Form is essential for participants in a health care flexible spending account (FSA) to claim reimbursement for eligible expenses. This guide provides clear, step-by-step instructions tailored to help users fill out the form accurately and efficiently.

Follow the steps to complete your reimbursement request effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor of your choice.
2. Complete the participant information section by entering your ID Number or Social Security Number, last name, first name, employer name, middle initial, and employer ID or client code.
3. In the expense reporting section, enter the Date of Service when the expense was incurred, then indicate the Type of Service using the provided codes such as Medical (MED) or Vision (VIS).
4. Describe the service provided (e.g., eyeglasses or dental work) and, if applicable, note the mileage driven to and from the provider for reimbursement of mileage expenses.
5. If there was sales tax charged for the item, enter that amount in the tax field. Then, input the Amount of service or item, as well as the Total Amount, ensuring to include both Amount and Tax.
6. Sign the form to attest that the information provided is complete and true. Include the date of signature.
7. Make copies of all supporting documentation required for your reimbursement, including itemized receipts and Explanation of Benefits.
8. Submit the signed form and copies of supporting documentation by faxing to 866-717-3820, or mailing to Ceridian FSA Services, P.O. Box 534451, St. Petersburg, FL 33747-4451.

Complete your Ceridian FSA Reimbursement Form online today to ensure you receive your reimbursements promptly.