Get Flex Plan Reimbursement Form

Filling out the FLEX PLAN REIMBURSEMENT FORM online can help streamline the process of obtaining reimbursement for eligible expenses. This guide provides step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to successfully complete your form.

1. Press the ‘Get Form’ button to access the FLEX PLAN REIMBURSEMENT FORM and open it in your preferred online editor.
2. Begin by filling in your information. Enter your full name in the 'Employee Name' field and the current date in the 'Date' section.
3. Input your Social Security number in the designated field and provide a contact phone number.
4. If you are claiming dependent care expenses, attach a receipt from your provider. Fill in the 'Name of Dependent,' specify the 'Period Covered,' and include the 'Name, Address & Taxpayer ID of Provider.' Enter the total amount being claimed.
5. For unreimbursed medical expenses, attach the appropriate receipts and input the 'Date of Expense' and 'Name of Service Provider.' In the 'Description of Expense' section, detail the nature of the expense and indicate the 'Person for Whom Expense Incurred,' followed by the amount.
6. If applicable, fill out details related to individual insurance premiums by providing the 'Name of Insurance Provider,' 'Insured Name,' type of insurance,' 'Date(s) of Coverage,' and the total amount.
7. Carefully read the authorization section and ensure the correctness of your statements. Sign and date the form at the bottom to confirm that you consent to the reimbursement request.
8. Once you have completed all the necessary fields and attached relevant receipts, save the form. You may choose to download, print, or share it as needed.

Take the next step towards reimbursements by completing the FLEX PLAN REIMBURSEMENT FORM online today.