Health Care Flexible Spending Account - fsafeds 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information in the EMPLOYEE (PARTICIPANT) INFORMATION section. Ensure you type or print clearly your last name, first name, home address, social security number, and contact numbers.
3. In the HCFSA REIMBURSEMENT REQUESTS section, list each patient’s last name and the dates of service. Specify the types of services provided and check the appropriate claim period box.
4. For each claim, enter the provider's name and address along with the reimbursement amount requested. Make sure to categorize each expense as Medical, RX, OTC, Dental, Vision, or Hearing Aid.
5. Complete all sections and ensure you sign and date the form at the end. Don’t forget to attach any required documentation such as EOB statements or itemized bills.

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