Fsa request for reimbursement form - Partner 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Client Name and Participant TASC ID in the designated fields. Ensure that you write legibly.
3. Fill out the Receipt Date of Service, ensuring you include the correct billing or paid date. This is crucial for processing your request.
4. List the Service Provider(s) and their corresponding Request Amounts. Remember, only four lines per form will be processed.
5. Review all entries for accuracy. Make sure all boxes and fields are completed before submission.
6. Submit your completed form along with receipts either by faxing to 877-233-5217 or mailing to TASC at PO Box 7308, Madison, WI 53707-7308.

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