Get Connect Your Care Heath Care Fsa Paper Claim Form

Completing the Connect Your Care Health Care FSA Paper Claim Form is essential for submitting your claims for reimbursement of qualified expenses. This guide provides clear, step-by-step instructions on how to accurately fill out the form to ensure a smooth submission process.

Follow the steps to complete your claim form easily.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in your personal information: Start with your employer's name, your own name (last name first), and your social security number.
3. Document your expenses: Under the 'Documentation Required' section, ensure to include the patient's name, a description of service, the date of service, and the amount charged. Use acceptable documentation formats like an Explanation of Benefits or an itemized statement.
4. Provide claim details: In the claim details section, enter the date of service, patient's name, their relationship to you, provider's name, description of service, and the total amount requested.
5. Complete the authorization and certification: Read the certification carefully. Sign and date the form to confirm that the expenses have been incurred and are not reimbursable by any other plan.
6. Submit the form: Once completed, you can fax the claim form and supporting documentation to (443) 681-4602 for faster processing or mail it to the provided claims department address.
7. Keep copies of all documents: Retain the original claim form and any documentation for your records.

Start filling out your claim form online now to ensure your expenses are reimbursed.