Get Flexible Spending Form

This guide provides comprehensive, step-by-step instructions for completing the Flexible Spending Form online. By following these easy-to-understand steps, you can ensure that your claims are processed accurately and efficiently.

Follow the steps to complete your Flexible Spending Form online.

1. Click ‘Get Form’ button to obtain the Flexible Spending Form and open it in your preferred editor.
2. Ensure that you fill in your employee information in Part 1, which includes your name, Participant ID, date of birth, and FSA Group Number provided by your employer.
3. In Part 2, enter the health care expenses. List each expense separately along with the dates of service and type of service rendered. Be sure to check the appropriate box for each service type.
4. Attach necessary documentation for your claims. If expenses were covered by a benefit plan, attach the Explanation of Benefits (EOB). For expenses not covered, include an itemized receipt with detailed information.
5. If applicable, complete Part 3 for dependent care expenses. Provide the dependent's name, date of birth, the type of services, and the amount requested for reimbursement. Ensure you have the day care provider certify the services rendered.
6. Review all entries on the form for accuracy and completeness. Make sure you include your employer’s name and FSA Group Number.
7. Sign and date the Certification for Reimbursement section at the bottom of the form certifying the expenses incurred.
8. Keep a copy of your completed form and all attached documentation for your records.
9. Finally, submit your completed form by mailing it to UnitedHealthcare or faxing it to the provided number. Ensure that it is postmarked or faxed within the filing deadline specified in your plan documents.

Complete your Flexible Spending Form online today to manage your expenses efficiently.