Get Ny Health Care Flexible Spending Account (hcfsa) Program Claims Form 2021-2025

The NY Health Care Flexible Spending Account (HCFSA) Program Claims Form is essential for seeking reimbursement for eligible healthcare expenses. Filling out this form correctly ensures a smooth and efficient claims process.

Follow the steps to fill out the HCFSA claims form confidently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter your employee (participant) information clearly in section 2. This includes your last name, first name, home address, city, state, zip code, daytime phone number, email address, agency name, and social security number. Be sure to check the box if this is a new address.
3. Move to section 3, 'HCFSA Reimbursement Requests.' Read the 'Instructions and Important Information' carefully before completing this section. You will need to enter details for each claim, including patient names, dates of service, types of service, provider information, and the amount you wish to be reimbursed.
4. For each claim, specify the date or dates of service in the format mm/dd/yy. Indicate whether the claim pertains to the current Plan Year or Grace Period by checking the appropriate box.
5. Complete the total reimbursement amount requested by adding each claim you entered above. Ensure the final total meets the minimum reimbursement requirement of $50 unless your account balance is lower.
6. In section 4, provide your signature and the date. Ensure you verify that all sections are completed, you have signed and dated the form, you have selected the correct claim period, and attached all necessary documentation such as Explanation of Benefits (EOB) statements and itemized bills.
7. Once all information is complete, save your changes. You may then download, print, or share the completed form as needed for submission.

Complete your HCFSA claims form online today for timely reimbursement!