FLEXIBLE SPENDING REQUEST FOR REIMBURSEMENT FORM - onu 2025

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Remember, to be accepted for a claim, youll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).
Who is eligible for an FSA? Generally, to be eligible for an FSA, you must be an employee of an employer who offers an FSA. (If you are self-employed, check out Medical Savings Accounts instead.) You could be eligible for one or more FSAs, which allow varying amounts you can contribute.
For health and limited health FSAs, you dont have to file anything with your return. You must file Form 2441 with your return if you have a dependent care FSA.
With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasnt been covered by your plan. Then, youll get reimbursed for your costs. Ask your employer about how to use your specific FSA.
Q: What documentation is required to verify the eligibility of my FSA expense? documentation containing 1) date of service, 2) type of service, 3) charged amount, 4) name of the provider, and 5) any insurance paid on the expense, if applicable, for each claim.

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A paper claim form must be submitted to UnitedHealthcare for processing. FSA Health Care Claim Forms are available online at .myuhc.com or via the Intranet at . Complete the claim form, then mail or fax to UHC with your itemized bill(s) or Explanation of Benefits (EOBs) for reimbursement.
Under the FSAFEDS Program, you must submit a completed FSAFEDS Health Care FSA claim form or FSAFEDS Dependent Care FSA claim form along with itemized receipts or other appropriate documentation, as described in this guide. Keep in mind that expenses are eligible on the actual date of service, not the date of payment.

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