Fsa request for reimbursement form - Partner 2026

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The document is a Request for Reimbursement form for Flexible Spending Accounts (FSA) intended for Stanford University participants. It outlines the process for submitting reimbursement requests, including required information such as participant details, service dates, and amounts. The form emphasizes the need for legibility, completion of all fields, and submission of receipts either by fax or mail to TASC. It also includes guidelines on eligible expenses and certification statements regarding the accuracy of the claims.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Client Name and Participant TASC ID in the designated fields. Ensure that you write legibly.
Fill out the Receipt Date of Service, ensuring you include the correct billing or paid date. This is crucial for processing your request.
List the Service Provider(s) and their corresponding Request Amounts. Remember, only four lines per form will be processed.
Review all entries for accuracy. Make sure all boxes and fields are completed before submission.
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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2015	4.8 Satisfied (63 Votes)

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