Get Fl Fbmc Claim Form For Fsa Hra And The Payment Card 2011-2025

Filling out the FL FBMC Claim Form for FSA, HRA, and the Payment Card online is a straightforward process that ensures you can receive reimbursement for eligible expenses. This guide provides step-by-step instructions to help you complete the form with confidence.

Follow the steps to successfully complete your claim form online.

1. Click ‘Get Form’ button to access the claim form and open it in your preferred editing tool.
2. In the Personal Data section, fill in your full name, home phone number, street address, city, state, and zip code. Additionally, provide your social security number or member ID, employer name, and daytime phone number. If you have a new address, mark the provided box.
3. Carefully read the certification statement and ensure you understand the commitments. You must sign and date the form in the Participant’s Signature section.
4. In the Payment Type section, indicate whether you used the payment card or if you are requesting reimbursement for out-of-pocket expenses. Fill in the corresponding claim amounts.
5. Complete the Medical FSA or HRA section by providing details of services received. Include the service date, the name of the person receiving the service, their relationship to you, the provider of services, and the amounts for which you are responsible.
6. If applicable, move to the Dependent Care FSA section and provide similar details for dependent care services, including service dates and any necessary signatures or statements.
7. Review the entire form for accuracy. Make sure you have attached all required documentation, such as receipts or bills, to support your claim.
8. Once the form is complete, save your changes, download the document, and consider printing a copy for your records before submitting it.

Complete your FL FBMC Claim Form online today to ensure timely reimbursement for your eligible expenses.