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Click ‘Get Form’ to open the HCFSA claim form in the editor.
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, phone number, and email address.
In the HCFSA REIMBURSEMENT REQUESTS section, list each patient’s last name and the dates of service. Specify the type of service provided and check the appropriate claim period box.
For each service, enter the provider's name and address along with the reimbursement amount requested. Make sure to separate claims by patient and date/type of service.
Finally, sign and date the form in the EMPLOYEE (PARTICIPANT SIGNATURE) section. Double-check that all sections are completed and that you have attached any necessary documentation before submitting.
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HCFSA REIMBURSEMENT REQUESTS. Each claim must be separated by patient, date/type of service and dollar amount. The minimum reimbursement amount requested must
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