Fbmc claim form 2026

1. Click ‘Get Form’ to open the fbmc claim form in the editor.
2. Begin by filling out the Personal Data section. Enter your name, home phone, street address, city, state, zip code, and SS# or Employee ID Number. Ensure all fields are completed using black ink.
3. Indicate if you have a new address by checking the appropriate box. This helps keep your records up-to-date.
4. In the certification section, read through the statements carefully and sign and date where indicated. This confirms your understanding of the terms.
5. For reimbursement requests, check the appropriate payment type boxes and enter the amounts for each applicable expense. Attach necessary documentation as specified.
6. Complete the Medical FSA or HRA section by detailing service dates, names of individuals receiving services, provider information, and amounts responsible for each service.
7. If applicable, fill out the Dependent Care FSA section with similar details regarding dependent care services provided.
8. Review all entries for accuracy before submitting your claim to avoid delays in processing.

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