Please send this form along with all applicable receipts to: 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information. Enter your full name, employer, last four digits of your Social Security Number, phone number, and email address in the designated fields.
3. If your address has changed, provide the new address along with the city, state, and zip code.
4. In the FSA Claim Information section, specify the type of expense for each entry. Include the date and amount for each medical expense incurred.
5. Ensure you complete all required fields for each type of expense listed. You can add multiple entries as needed.
6. Finally, sign and date the form at the bottom to confirm your agreement with the terms stated.

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