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Paychex fsa claim form 2026

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The document is a reimbursement claim form for Flexible Spending Accounts (FSA) related to unreimbursed medical expenses. It provides instructions for submitting claims, including required documentation and verification details. The form emphasizes the need for itemized bills and specifies that over-the-counter medications require a doctor's prescription. It also includes contact information for Paychex Employee Services and outlines the processing timeline for claims.

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Click ‘Get Form’ to open the Paychex FSA Claim Form in our editor.
Begin by filling out the Employee Information section. Enter your name, company name, last four digits of your Social Security Number, telephone number, and email address.
In the Service Recipient section, indicate the name of the person receiving the service and their relationship to you (self, spouse, or dependent).
For each service provided, enter the date of service, description (medical, dental, vision, or pharmacy), provider's name, and cost. Ensure all receipts are itemized and include necessary details as outlined in the instructions checklist.
After completing all sections, sign and date your claim form. Retain a copy for your records before submitting it via fax or mail as instructed.

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Versions	Form popularity	Fillable & printable
2015	4.8 Satisfied (155 Votes)
2011	4 Satisfied (32 Votes)

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