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(FSA) Claim Form - myuhc 2026
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- Click ‘Get Form’ to open the (FSA) Claim Form - myuhc in the editor.
- Begin by filling out the Employee Information section. Enter your employer's name, daytime phone number, and your personal details including your name, SSN, home address, and email address.
- In the Health Care Account section, list each eligible expense. For each entry, provide the patient’s name, relationship to you, date(s) of service, service provided, and the eligible reimbursement amount. Ensure you attach necessary documentation like EOBs or bills.
- For the Dependent Care Account section, include dependent details such as their name and birthdate. Attach a statement from your care provider that includes their information and signature.
- Review all entries for accuracy before signing and dating the form at the bottom. Make sure to keep a copy for your records.
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Related links
What is this form for? This form is for out-of-network claims ONLY, to ask for payment for eligible health care you have received.Read more
FLEXIBLE SPENDING ACCOUNT. (FSA) Dependent Care Claim Form. UnitedHealthcare. A UnitedHealth Group Company. MAIL CLAIM FORM TO: Health Care Account ServiceRead more