Follow the steps to successfully complete the claim form.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin with section A, Account Holder Information. Fill in the employer name and the plan year ending on. Provide the employee's full name, mailing address including street, city, state, and zip code. Don’t forget to include their Social Security Number or Employee ID and email address.
3. Proceed to section B, Health Care Reimbursement / Medical FSA. You will list each item for which you are seeking reimbursement. For each entry, include the item number, patient's first name, their relationship to the employee, the dates of service formatted as mm/dd/yy, the service provider's name, and the amount of the claim.
4. Continue filling out the remaining item lines (H1 to H8), if applicable, ensuring all necessary information is recorded. At the end of this section, calculate and enter the total amount being claimed.
5. Finally, review the Participant's Statement and provide your signature. This confirms your understanding that the information provided is complete and accurate, acknowledging that the expenses qualify under the plan.
6. Once you have completed the form, you can save your changes, download, print, or share the form as needed. Make sure to submit your claim by mail, fax, or email to the specified HR Simplified contact details.

Start filling out your MN HR Simplified Flexible Spending Account Claim Form online today!