Fsa claim form 2026

1. Click ‘Get Form’ to open the FSA claim form in our editor.
2. Begin by filling out Part 1, which includes your Employee Name, Identification Number, and Date of Birth. Ensure all information is accurate.
3. In Part 2, list your Health Care Expenses. For each expense, provide the Date(s) of Service, Type of Services (using the provided codes), and the total amount charged. Remember to attach any required documentation.
4. Proceed to Part 3 for Dependent Care Expenses. Fill in the Dependent’s Name and Date of Birth, along with the Dates of Services and Type(s) of Services provided. Attach a receipt that includes all necessary details.
5. Review your entries carefully. Sign and date the Certification for Reimbursement at the bottom of the form before submitting it via mail or fax.

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