Get Dependent Care Claim Form - Callutheran

Filing a Dependent Care Claim Form is essential for users seeking reimbursement for eligible dependent care expenses. This guide provides a clear and informative step-by-step process to assist you in completing the form accurately and efficiently.

Follow the steps to complete your Claim Form with ease.

1. Click ‘Get Form’ button to obtain the Dependent Care Claim Form and open it in your preferred digital editor.
2. Complete the Employee Information section. This includes entering your employer's name, your full name, account number or Social Security Number, street address, daytime phone number, city, state, and zip code.
3. In the Claim Information section, provide the Tax ID Number or Social Security Number for the dependent care provider. Fill in the provider's street address, city, state, and zip code, along with the dependent's name and date of birth. List the dates of service in the specified format (MM/DD/YYYY) and indicate the total amount requested for reimbursement.
4. Check the Provider Certification box if the dependent care provider has signed the form. If not, ensure that you attach an itemized statement from the provider that includes all required details.
5. Sign and date the Employee Certification section. By signing, you confirm the expenses are eligible and have not been submitted for reimbursement previously.
6. Submit your claim to CONEXIS Flexible Benefits Services either by fax to (877) 864-9555 or by mail to P.O. Box 226190, Dallas, TX 75222. Consider using fax for a quicker processing time.
7. Make sure to save any changes, download a copy, print it out if needed, or share the form as required.

Complete your Dependent Care Claim Form online today to ensure timely reimbursement for your eligible expenses.