Nd III. 3. Submit completed original claim form or original claim form and original statements/receipt to the address shown at right. Mail to: Fax: Print Dependent Care Flexible Spending Account Claims Mayo Clinic Health Solutions PO Box 211698 Eagan, MN 55121 1-855-619-0010 Section I Last Name (Account Holder) First Name Middle Initial Address City State Birth Date Social Security Number (last 4 digits) Home Phone Number Provider Name Employer Name Zip Code Work Phone N.
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How to fill out the Mayo Clinic 221-MMS349 online
Filling out the Mayo Clinic 221-MMS349 form for dependent care flexible spending account claims can be straightforward with the right guidance. This guide offers detailed steps to help users complete the form accurately and efficiently.
Follow the steps to effectively fill out the Mayo Clinic 221-MMS349 form.
- Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
- Begin by completing Section I, which requires the account holder's last name, first name, middle initial, and contact details such as the address, city, state, zip code, home phone number, and work phone number. Additionally, provide the provider's name and tax identification number.
- In Section I, identify the type of provider and list the names and ages of dependents for whom you are claiming services. Include the date(s) of service, the total work-related dependent care charges incurred, and ensure accurate totals are reflected.
- If the provider is unable to sign the form, attach an original itemized receipt or statement as documentation in Section II. This section requires the provider to confirm that services were performed and that the charges are accurate.
- In Section III, the account holder must certify that the expenses qualify for reimbursement under IRS guidelines. This includes affirming that the expenses have not been reimbursed elsewhere, and that they occur during the coverage period. Sign and date this section to confirm your understanding and responsibility.
- After completing the form, save your changes. You can then download, print, or share the form as needed to submit your claim.
Complete your Mayo Clinic 221-MMS349 form online to ensure timely processing of your claims.
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