Fsa claim form 2025

See details

4 out of 5

47 votes

The document is a claim form for the Flexible Spending Account (FSA) administered by UnitedHealthcare for the United States Postal Service. It outlines the process for submitting claims for health care and dependent care expenses, including required documentation and reminders for employees. The form includes sections for employee information, health care expenses, and dependent care expenses, along with instructions on how to complete each part and submit claims.

Here's how it works

01. Edit your fsa claim form 2022 online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out FSA Claim Form with DocHub

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

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.

Start using our platform today to easily fill out your FSA claim form online for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I submit a claim to FSA?

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 documentation is required for FSA reimbursement?

documentation can either be in the form of a receipt from the provider, or the provider can sign the claim form verifying the information listed is correct.

Do you get a form for FSA?

The funds in your Medical and Dependent Care FSA are deposited pre-tax and the amount is deducted from your Annual Gross Income. This will be represented on the W-2 you receive from your Employer for tax reporting. There are no additional tax forms issued for the FSA plans.

Can I submit a receipt to FSA?

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.

How do you get a FSA refund?

Set up direct deposit, and once a claim has been processed and approved, your reimbursement will be deposited directly into your bank account. This is the quickest and most secure way to receive your reimbursements. Plus, theres no waiting around for a check in the mail.

How are FSA claims reimbursed?

Payment Options. Set up direct deposit, and once a claim has been processed and approved, your reimbursement will be deposited directly into your bank account. This is the quickest and most secure way to receive your reimbursements.

How do you submit FSA claims?

How do I submit a Federal Flexible Spending Account Program (FSAFEDS) online claim? You can submit your claim online by logging into My Account Summary at .FSAFEDS.com , clicking on My Claims, and selecting Online Claim Submission. You must upload an image of your supporting documentation in .

How long does it take to submit FSA claims?

You should submit claims for reimbursement during the plan year, but in no event later than 60 days after the end of a plan year.

Fsa claim form 2025

Here's how it works