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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your name, Social Security number, and employer name. Ensure accuracy as this information is crucial for processing your claim.
For the Dependent Care Spending Account section, provide details about your dependent, including their name and age. Specify the care provider's name and address, type of service provided, and the dates care was given.
In the Medical Spending Account section, list the date(s) of service, health care provider's name, type of expense incurred, and patient relationship. Make sure to include all amounts requested for reimbursement.
Review all entries for completeness and accuracy. Sign where indicated to certify that all information is correct before submitting your claim.

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Is FSA worth it if I have HSA?

If you expect to have high medical costs throughout the year or want to maximize contributions to your HSA while minimizing your withdrawals, using a limited-purpose FSA for expected vision and dental expenses could be a smart choice.

What is the biggest disadvantage of the FSAs?

Cons of a Flexible Spending Account Use-It-Or-Lose-It Rule: Unused FSA funds are forfeited unless your employer offers a grace period or carryover option. Eligibility Restrictions: FSAs only cover qualifying medical expenses, dental and vision costs, and dependent care expenses.

How to avoid losing FSA money?

Make sure to check you election amount and estimated expenses every year and adjust as needed. Know important deadlines and carryover amounts: Use-it-or-lose it provisions apply to FSAs so its important to know the deadlines for using funds and filing claims.

What happens to unused money in a flexible spending account?

The IRS created the use or lose rule, which states that all money left in your FSA is forfeited after the benefit period ends . If you dont use all of your FSA funds during the benefit period, you risk losing money.

How to make the most of your FSA money before it disappears?

Common purchases include everyday health care products like bandages, thermometers and glasses. Everything from medical expenses that arent covered by a health plan (like deductibles and co-pays to dependent day care) to over-the-counter medication can also be eligible.