Infinisource fsa reimbursement form 2026

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The document is a Reimbursement Form for employees to claim expenses under Health Flexible Spending Accounts (FSA) and Health Reimbursement Arrangements (HRA). It outlines the necessary information required for submission, including patient and provider details, expense types, and documentation requirements. The form also includes sections for dependent care claims and certifies that the expenses have been incurred as per IRS guidelines. Instructions for completing the form, submitting claims, and appealing denied claims are provided.

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Click ‘Get Form’ to open the infinisource FSA reimbursement form in the editor.
Begin by entering your personal information, including your name, ID or SSN, employer, and address. If your address has changed, check the corresponding box.
Provide your daytime phone number and email address. Optionally, include a mobile number for text confirmations regarding your claim.
For health-related claims, fill in the patient’s name, provider details, type of service, date of expense, and amounts. Ensure you attach any required documentation as specified on the reverse side.
If submitting dependent care claims, complete the relevant sections with dependent details and provider information. Remember to have the provider sign if no receipt is available.
Finally, review all entries for accuracy and sign the form before submitting it via mail or fax as instructed.

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How do I submit an FSA reimbursement?

You must submit a claim each time you request reimbursement for dependent care expenses, even if you regularly pay your dependent care provider the same amount each week. You will be reimbursed up to the current amount in your DCFSA at the time your claim is processed.

How do I get reimbursed from my FSA?

How do I submit a Federal Flexible Spending Account Program (FSAFEDS) online claim? You can submit your claim online by logging into My Account Summary at .FSAFEDS.com , clicking on My Claims, and selecting Online Claim Submission. You must upload an image of your supporting documentation in .

How do I submit a claim to the FSA?

You can use the funds from your FSA either with an FSA debit card provided by your employer, or by submitting paper receipts for reimbursement of FSA eligible expenses. You can use your FSA debit card at any approved pharmacy or store that accept these special cards.

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