Get Gilsbar Fsa Reimbursement Form - Mark Iii Employee Benefits

This guide provides step-by-step instructions for efficiently completing the Gilsbar FSA Reimbursement Form - Mark III Employee Benefits online. By following these clear instructions, users can ensure accurate submissions for reimbursements related to their flexible spending accounts.

Follow the steps to fill out your reimbursement form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your employee name and Employee ID or Social Security Number (SSN) in the designated fields.
3. Provide your current daytime phone number and email address to ensure that the claims processing team can reach you if needed.
4. Fill in your employer's name at the appropriate section to identify your affiliation.
5. For the Health Care Reimbursement Claim (HCRA), you must attach a bill, receipt, or Explanation of Benefits (EOB) that verifies the details of the service or product. Enter the date of service, type of service, name and relationship of the person receiving the service, and the amount claimed for each visit.
6. If you have multiple claims, list them sequentially, ensuring to use additional sheets if necessary.
7. Sum the total amount requested for Health Care reimbursements in the provided space.
8. For the Dependent Care Reimbursement Claim (DCRA), attach a receipt from the dependent care provider that includes the dependent's name, date of birth, and the provider's tax ID or SSN. Enter the details for each service rendered, following the same structured process as in the health care section.
9. Have the dependent care provider sign and date the certification area if the receipts are not being attached.
10. Finally, certify your request by signing the form and dating your signature, confirming that the claims comply with the FSA/HRA Plan.
11. Once all sections are completed, review your form for accuracy before saving changes, downloading, printing, or sharing the completed form for submission.

Complete your Gilsbar FSA Reimbursement Form online today to ensure your reimbursements are processed promptly.