Follow the steps to complete your Medcom Ed 0669 form online.

1. Click the ‘Get Form’ button to access the Medcom Ed 0669 form and open it in the designated editor.
2. Begin by entering your employee name in the space provided at the top of the form. Ensure it is printed clearly to avoid any processing delays.
3. Next, input your Social Security number in the designated area. Accuracy in this section is crucial for proper identification.
4. Attach the necessary substantiation for your claims. Medical claims require the Insurance Explanation of Benefits, a medical provider invoice with a diagnosis, or a prescription. For dependent day care claims, itemized invoices with payment frequency, provider's name, tax ID, dates of service, and the name of the individual receiving the service must be included.
5. Indicate the amounts you are requesting reimbursement for. Fill in the total medical expenses in the FSA section and the total dependent day care expenses in the DCAP section.
6. For DCAP claims, answer the two additional questions regarding payment frequency and employment status during the claim period. This affects the eligibility of your claim.
7. List the names (such as child or spouse) of dependents for whom expenses were incurred on the form.
8. List the total number of business days not worked if applicable. This is required for validating your DCAP claims.
9. Incurred dates for services must also be filled in, along with itemizing and totaling your expenses for FSA and DCAP.
10. After completing the form, ensure you sign and date it at the bottom, certifying the accuracy of your claim.
11. Finally, review all entries for accuracy. You may then save your changes, download, print, or share the filled form as necessary.

Complete your Medcom Ed 0669 form online now to ensure timely processing of your claims.