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How to use or fill out FSA SUBSTANTIATION FORM with our platform
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Click ‘Get Form’ to open the FSA SUBSTANTIATION FORM in the editor.
In SECTION I, provide your Employee Information. Fill in your full name as it appears on your FSA debit card, Social Security number, address, email, and phone number. Ensure all details are printed legibly.
Move to SECTION II for FSA DEBIT CARD PURCHASE INFORMATION. Enter the purchase date and total amount for each transaction you need to substantiate. Include the merchant or service provider's name and check the box if you do not have a receipt.
In SECTION III, certify that the expenses qualify for reimbursement by signing and dating the form. This confirms that you understand the requirements and have attached necessary documentation.
Finally, follow SECTION IV directions to submit your completed form along with itemized receipts. You can fax or mail them but avoid sending both.
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Please save your receipts and other supporting documentation related to your HC FSA expenses and claims. The IRS may request itemized receipts to verify the eligibility of your expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.
What documentation is needed for 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.
What is a substantiation on a FSA debit card?
Auto-substantiation occurs when your purchase can be verified as eligible at the point-of-sale. For example, a prescription at a pharmacy or a purchase on FSAStore.com. This accounts for 85% of all debit card purchases. Manual Substantiation occurs when your card swipe does not auto-substantiate.
What is an FSA document?
An arrangement through your employer that lets you pay for many out-of-pocket medical expenses with tax-free dollars. Allowed expenses include insurance copayments and deductibles, qualified prescription drugs, , and medical devices.
What form is FSA?
You must file Form 2441 with your return if you have a dependent care FSA.
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How to submit a FSA form?
Online Submission Log in to the FSAFEDS app using the same username and password as your online account. Select whether to submit a claim or pay a provider. Follow the prompts to enter claims details. Take photos of your itemized receipts (and other documentation if needed) or upload from your mobile device.
What information is required for FSA reimbursement?
Date of Service: The date on which services were provided or the item was purchased. Type of Service: A detailed description of the service provided or item purchased. Cost: The amount you paid for the service or product and/or the portion that is not reimbursed through your insurance carrier.
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fsa-forms-and-downloads
Forms and documents can be submitted electronically to: . Please do not submit your form/document more than once. This will only
Feb 4, 1986 The substantiation rules in this section apply to limited- purpose health FSAs and to post-deductible health FSAs. In addition to providing
This form is intended to substantiate purchases made with your Discovery Benefits debit card. Requests for reimbursement of out- of-pocket expenses need to be
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