Connect Your Care Heath Care FSA Paper Claim Form 2026

1. Click ‘Get Form’ to open the Connect Your Care Heath Care FSA Paper Claim Form in the editor.
2. Begin by filling out the 'Personal Information' section. Enter your employer's name, your full name (last name, first name), and your Social Security Number.
3. In the 'Documentation Required' section, ensure you have acceptable documentation ready. This should include the patient's name, service description, date of service, and amount charged.
4. Proceed to the 'Claim Details' section. Fill in the date of service, patient’s name, relationship to employee, provider's name, description of service, and total amount requested.
5. Read through the 'Authorization and Certification' statement carefully. Sign and date this form to certify that all information is accurate.
6. Finally, submit your completed form by faxing it along with required documentation to (443) 681-4602 or mailing it to the provided address for claims.

Start using our platform today for free to streamline your claim submission process!