Get Dependent Care Claim Form Fax To: 1.866.791.0252 Mail To ...

This guide provides a clear and supportive overview for users on how to fill out the Dependent Care Claim Form effectively. Follow these instructions to ensure your claim is completed accurately and submitted promptly.

Follow the steps to properly complete your Dependent Care Claim Form.

1. Begin by using the ‘Get Form’ button to obtain the Dependent Care Claim Form. This allows you to access the form in your preferred electronic format.
2. Complete Section 1 of the claim form, providing your personal information including employer or group name, social security number, participant last and first name, daytime phone number, and participant email.
3. Move to Section 2 to list your expenses. Choose the appropriate expense code for childcare or adult care, and ensure you provide the service start and end dates, dependent's name, the amount charged, and the care provider's name and tax ID.
4. If this claim is a resubmission, be sure to check the corresponding box in Section 2.
5. Have the care provider sign the provider affidavit section at the bottom of each expense entry, certifying the charges have been incurred. Include the date of their signature.
6. In Section 3, read the self-certification statement carefully, and upon agreement, sign and date the form to authorize reimbursement from your Dependent Care Flexible Spending Account (DCFSA).
7. Make copies of all receipts before submitting. Keep originals for your records as requested only copies are required.
8. Once completed, fax the original claim form to 1.866.791.0252 or mail it to the address provided: Bank of America Benefit Solutions, PO Box 25165, Lehigh Valley, PA 18002-5165.
9. After submission, consider utilizing features such as direct deposit for faster payment and email updates for tracking your claim status.

Get started on your Dependent Care Claim Form today to ensure timely reimbursement!