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

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The document is a claim form for Health and Dependent Care Flexible Spending Accounts provided by PayFlex Systems USA, Inc. It outlines the process for submitting claims for reimbursement of eligible medical expenses and dependent care costs, including necessary documentation and eligibility criteria. The form includes sections for employee information, details of services rendered, and certifications regarding the incurred expenses.

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Click ‘Get Form’ to open the PayFlex Health Dependent Care FSA Claim Form in the editor.
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.
Fill in your Employer Name accurately. If you need to change your address, contact your HR/Benefits department directly.
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.
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.
Finally, sign and date the form certifying that all information is accurate and that expenses have not been reimbursed elsewhere.

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2010	4 Satisfied (30 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do you use dependant care in FSA?

With a Dependent Care FSA, you use pre-tax dollars to pay qualified out-of-pocket dependent care expenses. The money you contribute to a Dependent Care FSA is not subject to payroll taxes, so you end up paying less in taxes and taking home more of your paycheck.

How do I file a claim with PayFlex?

If I participated in a Health Care FSA, do I need to report anything on my personal income tax return at the end of the year? No. There are no reporting requirements for Health Care FSAs on your income tax return.

How long does it take to submit a dependent care FSA claim?

Important Timelines: Employees have 120 days after the end of the Plan Year to submit claims for dependent care expenses. A terminated employee has 120 days from date of termination to submit claims for eligible daycare expenses incurred prior to the termination date.

How to submit dependent care FSA claim?

Dependent Care FSA Use the FSAFEDS app to have the dependent care provider docHub the service by providing a signature on your mobile device. Have the dependent care provider docHub the service by signing the completed claim form (PDF). Submit a claim (PDF) with an itemized statement from the dependent care provider.

How to submit claim for dependent care in FSA?

Go to payflex.com and click Documents Forms at the top of the page. Select Administrative Forms and click Flexible Spending Account Claim Form. Complete all fields of the form. Sign and date the form. Mail or fax your completed claim form and supporting documentation to PayFlex.

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What kind of receipt do I need for dependent care FSA?

Receipts must state the provider name, provider contact information, the dependent name, service dates (begin and end), a description of the service and the expense amount. A credit card receipt or canceled check is not adequate documentation.

Do I need to report FSA on tax return?

Theyll help to ensure less paperwork and faster reimbursement. For each claim, you must send a completed and signed claim form with supporting documentation. Claim forms are available on pebc.payflex.com. Online Claim Filing: You can file your claim online.