Get Fsa Claim Form - Unreimbursed Medical - Advantek Benefit ...

Filling out the FSA Claim Form for unreimbursed medical expenses is a straightforward process that can be completed online. This guide provides clear, step-by-step instructions to ensure that you successfully submit your claim for reimbursement.

Follow the steps to complete your claim form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your employer's name and your member number or the last four digits of your Social Security number in the designated fields.
3. Provide the employee's name in the appropriate section, ensuring that it matches the information on file.
4. Fill in the date the expense was incurred. Be precise to avoid any issues with your claim.
5. Specify the name of the service provider to whom the payment was made.
6. Describe the expense in detail, including the nature of the service provided or the item purchased.
7. Indicate the person for whom the expense was incurred. This can be the employee or a dependent.
8. Enter the total amount of the expense, followed by the net amount after any applicable deductions.
9. Review the certification statement carefully, ensuring that all provided information is accurate and truthful.
10. Sign and date the form to validate your claim submission.
11. Attach any necessary receipts that show the date of service and the items rendered or purchased.
12. Once all fields are filled, review the form for completeness and accuracy, then proceed to save, download, print, or share the form as needed.

Complete your FSA claim form online today to ensure timely reimbursement for your medical expenses.