Get Fsa Disbursement Form - Sterling Hsa

This guide provides you with step-by-step instructions on how to accurately fill out the FSA Disbursement Form - Sterling HSA online. By following these instructions, you will ensure a smooth and efficient disbursement process.

Follow the steps to complete the FSA Disbursement Form online.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred editor.
2. Begin by entering your employee information. In the designated fields, provide your name, Social Security Number (SSN), and your current address. Be sure to indicate if you want to change the address on your account or permanently update it.
3. Fill out your email address and phone number for communication purposes. Ensure that your city, state, and zip code are also accurately entered.
4. In the section for medical expenses, list the persons for whom the expenses were incurred. Input the date(s) of service, the name and address of the service provider, a description of the expenses, and the amount billed.
5. If applicable, fill out the dependent care/daycare expenses section. Include the dependent’s name, age, and relationship to you, as well as the date(s) of service, provider's name and address, and the corresponding amounts.
6. Attach any required supporting documentation for all expenses being claimed. This documentation must include the service provider's name, address, amount billed, service description, and actual dates of service.
7. Review the certification statement carefully. Confirm that all provided information is accurate, and acknowledge your responsibility for the validity of the request.
8. Sign and date the form to certify your claims. Ensure that your signature is legible.
9. Finally, choose your submission method. You can mail the form to the listed address, email it to customer.service@sterlinghsa.com, or fax it to 888-410-7361. Consider saving any changes, downloading, or printing the document for your records.

Complete your FSA Disbursement Form online today for a hassle-free reimbursement process.