Fillable Fsa Claim Form printable pdf download

FSA Claim Form

EMPLOYEE INFORMATION

Name: ________________________________________________ Last four digits of your Social Security #: ___ ___ ___ ___

Address: ______________________________________________ Company Name: _________________________________

City/State/Zip: _________________________________________



Please check box if address is new

Dependent Care Reimbursement

Service period

Name, Address, Taxpayer identifier number

Name of Dependent

From

of provider of service

Charge of Service

Total Dependent Care Amount Requested:

I provided the dependent care as stated above. _________________________________________ _______________ ___________

Provider’s Signature

Date

SSN/Tax ID

Flexible Medical Benefits

Patient’s Name

Type of Services

Date(s) of Service

Healthcare

Amount of

Please Check One Box Below for Each Expense Type

mm/dd/yyyy

Mileage*

Charge

MD=Medical, Rx=Prescription, DN=Dental, VS=Vision

$0.23 per

OTCS=Over-the-Counter Supplies

mile**

OTCD=Over-the-Counter Drug (Must include Rx along with receipt)

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

From:

To:

OTCS

OTCD

NOTE: EVERY OTC DRUG CLAIM REQUIRES A COPY OF THE

Total Medical Amount Requested:

PRESCRIPTION TO BE ATTACHED.

Please arrange documentation in order listed above.

The undersigned participant in the Plan certifies that all expenses for which reimbursement or payment is claimed were incurred during the current period under the

company’s Cafeteria Plan. The undersigned participant in the Plan understands that expenses are “incurred” when a service is performed or care is provided, not when

the bill is paid. The undersigned certifies that all expenses for which reimbursement or payment is claimed on this form were incurred on the dates of service

stated above. The undersigned fully understands that he or she is alone fully responsible for the sufficiency, accuracy, and veracity of all the information relating to this

claim and unless an expense for which payment or reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related

taxes including Federal, State, or City income tax on amounts paid from the Plan which relate to such expense.

____________

Employee’s Signature

(must be signed for proper processing)

Date

To Submit a Claim:

•

and submit your claim electronically through the Employee Portal, (click on Employee, Employee Login)

Visit us at:

•

Submit your medical claim via our new mobile app, BeneFlexHR Mobile. (available on iTunes or Google Play), or

•