Flex Account Reimbursement Form - JW Terrill 2025

1. Click ‘Get Form’ to open the Flex Account Reimbursement Form in the editor.
2. Begin by filling out the Employee Information section. Enter your employer's name, daytime phone number, and your personal details including your full name, SSN, home address, and email address.
3. In the Health Care Account section, list each eligible expense. For each entry, provide the patient’s name, relationship, date(s) of service, service provided, and the eligible reimbursement amount. Remember to attach necessary documentation like insurance EOBs.
4. For the Dependent Care Account section, include dependent details such as name and birthdate. Provide information about the care provider along with their Taxpayer ID or SS#. Attach relevant invoices or receipts for services rendered.
5. Finally, review all entries for accuracy. Sign and date the form before submitting it via mail or fax as indicated on the document.

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