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Fsa claim form 2026
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- Click ‘Get Form’ to open the FSA claim form in our editor.
- Begin by filling out Part 1, which includes your Employee Name, Identification Number, Date of Birth, Address, and Daytime Telephone Number. Ensure all information is accurate.
- In Part 2, list your Health Care Expenses. For each expense, provide the Patient’s Name, Dates of Service, Type of Services (using the provided codes), and the Request Amount. Remember to attach any required documentation.
- Complete Part 3 for Dependent Care Expenses by entering the Dependent’s Name and Date of Birth. Include Dates of Services and Request Amounts for each service provided.
- Review all sections carefully to ensure accuracy. Sign and date the Certification for Reimbursement at the bottom before submitting your claim.
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