Get Fsa Reimbursement Request Form - Keenancom

Filling out the FSA Reimbursement Request Form is an essential step for users seeking reimbursement for eligible health care expenses. This guide will provide clear, step-by-step instructions on how to effectively complete the form online.

Follow the steps to successfully complete your request form.

1. Click ‘Get Form’ button to access the FSA Reimbursement Request Form and open it in your editing tool.
2. Begin by completing Part I: Employee Information. Fill in your employer's name, your full name (last, first, and middle initial), your Social Security Number, address, daytime phone number, and email address. If your address has changed, check the box indicating that it is a new address.
3. In Part II: Health Care Claims, indicate whether services were covered by insurance or not. If they were covered, submit a copy of the Explanation of Benefits Statement along with your claim. If not covered, provide an itemized statement from the service provider that includes details such as the provider’s name, patient name, date of service, description, and amount charged.
4. For prescription and over-the-counter medications, include a print-out of prescriptions from your pharmacy or an itemized receipt that identifies the items clearly. Make sure the total amount requested is filled out correctly.
5. For Part III: Dependent Child or Adult Day Care Claims, fill in the required details about the care services provided. This includes dates of service, name of the dependent, and any statements from your day care provider. Ensure that the provider’s information, including their Tax Identification Number or Social Security Number, is accurate.
6. As part of the certification process, read through the statement provided regarding the eligibility of the expenses, and sign your name and date the form. Remember to keep copies of all documents submitted, as originals will not be returned.
7. Finally, review all filled-out sections for accuracy, save your changes, and choose to download, print, or share the form as necessary.

Complete your forms online now to ensure timely processing and reimbursement.