Health Care Fsa Claim Form
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4Submitting Your Health Care FSA Claim
How To File a Health Care Claim
To complete a Health Care reimbursement request (a claim), you must submit a Health Care FSA Claim Form along with
the receipts that clearly show an eligible expense was incurred. To complete a reimbursement request, you should:
1.
Complete a Health Care FSA Claim Form
2.
Attach itemized documentation
COMPLETE
ATTACH
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2
3
FAX
3.
Submit the form and documentation to ADP
FORM
RECEIPTS
The Claim Form must be completed entirely, dated and signed. The supporting receipts or billing statements must state
the vendor name, vendor contact information, purchase date, a description of the expense(s) and the expense amount. An
Explanation of Benefits (EOB) from your medical provider can also be used as supporting documentation for your claim. A
credit card receipt or canceled check is not adequate documentation. Credit card receipts often do not list the individual
items purchased along with a description of the item. This is why you must save your purchase receipts, bills, itemized
statements or EOB. Health Care claims cannot be processed for payment without proper supporting documentation.
You may submit up to four (4) purchases on a single Health Care Claim Form, using a separate line for each purchase.
Please fax (fastest process) OR mail the documents, but please DO NOT DO BOTH. Be sure to keep a copy of your
claim.
Place the documents in this order: Health Care Claim Form first, then the supporting
documentation. Please do not return the instruction pages with your form and receipts.
Fax to: 866-392-4090 (toll-free) or 678-762-5900
OR
Mail to: ADP Claims Processing, P.O. Box 1853, Alpharetta, GA 30023-1853.
Good Receipt
Receipt Missing Information
no description of
items purchased
Why Providing Documentation Is Important
The IRS has provided strict requirements stating that expenses reimbursed through a Flexible Spending Account must be
substantiated using itemized receipts, bills, statements or Explanation of Benefits. All supporting documentation must
reflect the vendor name, vendor contact information, date purchase/expense was incurred, a description of the expense
and the expense amount. Health Care claims submitted without eligible documentation cannot be approved for payment,
per IRS regulations. If your claim is declined for improper documentation, or if the expense is deemed as ineligible, you
will be notified by ADP via U.S. Mail Service.
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