Hr simplified claim form 2026

1. Click ‘Get Form’ to open the hr simplified claim form in the editor.
2. Begin by filling out the Account Holder Information section. Clearly print your employer name, employee name, mailing address, social security number or employee ID, and email address.
3. In the Health Care Reimbursement / Medical FSA section, list each item for reimbursement. For each entry, provide the patient's first name, their relationship to you, the date(s) of service, service provider details, and the amount of claim.
4. Ensure that all information is accurate and complete. Double-check that you have not previously been reimbursed for these expenses.
5. Sign and date the Participant's Statement and Signature section to certify that your statements are true.
6. Finally, submit your completed form by mail, fax, or email as indicated at the bottom of the document.

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