Get Fsa Reimbursement Form.pdf - Infinisource

Filling out the FSA Reimbursement Form is a straightforward process that allows users to claim expenses related to health or dependent care. This guide provides clear, step-by-step instructions for completing the form effectively.

Follow the steps to ensure your reimbursement request is accurately submitted.

1. Press the ‘Get Form’ button to obtain the FSA Reimbursement Form and open it in your preferred editor.
2. Fill out your personal information at the top of the form, including your name, employee ID or Social Security Number, address, daytime phone number, email, and the employer's name. If your address has changed, check the corresponding box.
3. Indicate whether you want your healthcare claims processed under the Health Reimbursement Arrangement (HRA) and Health Flexible Spending Account (FSA) benefits by marking the appropriate checkbox.
4. For health-related claims, fill out the details for each expense, including the patient name, provider information, type of service, date of service, expense amount, and any insurance payments received. Ensure this information matches your documentation.
5. For dependent care claims, provide the dependent's name, relationship, age, and the provider's information, along with the service dates and amounts. Include the provider's signature if a receipt is not provided.
6. Carefully read and check the certification statements at the bottom of the form. You must certify that the provided information is correct and complete.
7. Sign and date the form in the designated area. Your signature is a requirement for processing your reimbursement.
8. Attach any required documentation as specified in the instructions. Review to ensure all necessary documents are included.
9. Finally, save your changes, download a copy of the completed form, and either print or share it as needed. Mail or fax the form to Infinisource at the addresses provided.

Complete your FSA Reimbursement Form online today to ensure timely processing of your claims.