Tation. File claim via fax or mail: Claim details may be entered online and a completed form may be printed and faxed or mailed with documentation. Toll-free Fax: 866-643-2245, US Mail: FSAFEDS Program Claims, P.O. Box 14127, Lexington, KY 40512-4127 If you have questions: Visit the FSAFEDS website at www.FSAFEDS.com or contact an FSAFEDS Benefits Counselor toll-free at 877-FSAFEDS (372-3337), TTY: 866-353-8058, Monday through Friday from 9 a.m. until 9 p.m., Eastern Time. Who expenses.
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How to fill out the FSAFEDS 4119-FEDS online
Filling out the FSAFEDS 4119-FEDS form online is a straightforward process that enables users to submit claims for eligible healthcare expenses efficiently. This guide provides clear instructions to help you navigate each section of the form with ease.
Follow the steps to complete your FSAFEDS 4119-FEDS form.
- Click ‘Get Form’ button to obtain the form and open it for completion.
- Begin by entering your account holder information. Complete all required fields including your last name, first name, employer information, and ID code, which is the last four digits of your Social Security number.
- Next, provide the details of the service provider. Input the provider's name, service date(s), and the patient's name along with their relationship to you.
- Select the type of service provided from the available options such as RX, dental, or vision.
- Enter the out-of-pocket cost for each service. If applicable, ensure your provider signature is included to verify the service.
- Review all the entered information for accuracy. Ensure that documentation to support your claim is ready to upload or to be included if filing via fax or mail.
- Once you are satisfied with the form, save your changes, and either download, print, or share the form as needed for submission.
Complete your FSAFEDS 4119-FEDS form online today to ensure timely reimbursement for your eligible healthcare expenses.
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