Keenan flexible spending account 2026

1. Click ‘Get Form’ to open the keenan flexible spending account reimbursement request form in the editor.
2. In Part I, fill in your Employee Information. Include your Employer Name, Employee Name (Last/First/MI), SSN, Address, Daytime Phone Number, and Email Address. If you have a new address, check the corresponding box.
3. Move to Part II for Health Care Claims. If expenses are covered by insurance, submit them first to your insurance company and attach the Explanation of Benefits (EOB) with this form. For non-covered expenses, provide an itemized statement from your provider detailing the service.
4. List any family members receiving services in the designated section along with the type of service provided and dates of service. Ensure you calculate and enter the total reimbursement request amount accurately.
5. In Part III for Dependent Child or Adult Day Care Claims, complete the required information about your day care provider or have them fill it out directly on the form.
6. Finally, certify that all expenses are eligible by signing and dating the form before submission. Remember to keep copies for your records.

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