PayFlex Health Dependent Care FSA Claim Form PayFlex Health Dependent Care FSA Claim Form 2026

1. Click ‘Get Form’ to open the PayFlex Health Dependent Care FSA Claim Form in the editor.
2. Begin by entering your Employee Name and Member Number at the top of the form. This may be your Social Security Number or an employer-assigned number.
3. Fill in your Employer Name accurately. If you need to change your address, contact your HR/Benefits department directly.
4. For Health Care Claims, indicate whether expenses are covered by insurance. Attach the Explanation of Benefits (EOB) from your insurance company along with any itemized statements for copays.
5. For dependent care claims, provide details about the service dates, dependent names, and amounts requested. Ensure you attach an itemized statement from your day care provider or have them complete the required section on the form.
6. Finally, sign and date the form certifying that all information is accurate and that expenses have not been reimbursed elsewhere.

Start filling out your PayFlex Health Dependent Care FSA Claim Form online for free today!