Adp Fsa Claim Form – Fill Out and Use This PDF

The ADP Flexible Spending Account (FSA) Claim Form is a crucial document for employees looking to get reimbursed for their healthcare expenses. This form allows for the submission of claims for expenses that are eligible under the healthcare plan but not fully covered, such as co-payments and certain over-the-counter medications prescribed by an eligible healthcare provider. For guidance on filling out the form and a detailed list of eligible medical expenses, individuals are encouraged to visit myspendingaccount.adp.com. If ready to seek reimbursement for healthcare expenses, click the button below to proceed with the form completion.

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Adp Fsa Claim Form PDF Details

Managing healthcare expenses can often feel overwhelming, especially when trying to navigate the various forms and processes to ensure you receive the reimbursements you're entitled to. The ADP Flexible Spending Account (FSA) Claim form is designed to streamline this process, offering a structured way for individuals to request reimbursement for healthcare expenses not fully covered by insurance or benefit plans. From co-payments for medical services to prescribed over-the-counter medicines and other eligible healthcare expenditures, this form acts as a guide to help ensure that you can claim what you're owed efficiently. It requires detailed information, including personal data, the nature of the healthcare expenses incurred, and the necessary documentation to support these claims. The form outlines a step-by-step process, including how to correctly fill it out, attach the supporting documentation, and submit it for reimbursement, with options for faster processing through fax or direct deposit. Additionally, the form provides information on eligible medical expenses and the importance of adhering to the instructions to avoid delays or denials in reimbursement. It acts as a vital tool for managing healthcare costs effectively, ensuring that individuals can navigate their expenses with greater ease and confidence.

Question	Answer
Form Name	Adp Fsa Claim Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	adp reimbursement, adp new employee information form, flexdirect adp, myspendingaccount adp com

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HOW TO REQUEST REIMBURSEMENT FROM YOUR FLEXIBLE SPENDING ACCOUNT

This form is to be used to request reimbursement for healthcare expenses only. To view a detailed list of eligible medical expenses, visit myspendingaccount.adp.com. All healthcare expenses should irst be iled under your employer’s healthcare plan or any other COVERAGE you may have. Generally, eligible expenses include: allowable expenses covered but not fully reimbursed by any beneit plans, such as co-payments; and allowable expenses NOT covered by any beneit plans, such as over-the-counter medicines prescribed by an eligible healthcare provider.

Step 1: Fill out the form

• Please print in capital letters, with your letters centered in the boxes provided and ill in all ovals as shown:

A	B	C	D		1	2	3	4	YES NO

•For Sections 2 & 5: Complete a separate line for each individual expense. Do not lump expenses together.

•Complete all sections of the form. Sign and date the bottom of the form.

•If your expenses exceed the number of lines provided, please use page 3.

Step 2: Attach supporting documentation

•Copy your receipts or other supporting documentation onto a white, letter-sized sheet of paper. Place your receipts so they all face the same direction and write your Social Security Number or employee ID at the top of the page.

Step 3: Submit your form (Faxing is faster)

•By Fax: Send the form and copied receipts together as one fax. Do not include a fax cover sheet.

•By Mail: Place the form and the supporting documentation into an envelope, apply the correct postage, and mail.

•If you provide your e-mail address, ADP will e-mail you conirmation we received your form.

•Keep a copy of your completed form and receipts for your records.

Step 4: Receive your reimbursement (Direct Deposit is faster)

•By using Direct Deposit or Electronic Funds Transfer (EFT), you will receive your reimbursement funds up to ive days faster than by receiving a check. To sign up, log in to your account at myspendingaccount.adp.com and select “Direct Deposit” from the left-side menu.

Type of Supporting Documentation:

•Itemized receipt from your medical, dental or vision provider or pharmacy.

•Claims for OTC medicines must include a pharmacy prescription receipt showing the name of the person for whom the prescrip- tion applies, the date of service, amount of the purchase and an Rx number.

•Detailed statement, such as an Explanation of Beneits (EOB) from your insurance company or healthcare provider.

•Documentation must show date of service or purchase, type of service or name of product, amount (your portion of payment).

Please Do NOT:

•Use red ink

•Use a photocopy of the form

•Highlight receipts or any part of the form

•Staple your copied receipts to the form

•Write outside the boxes provided

•If faxing, fax the same form more than once

•Mail the same form that you have faxed

•Include this instruction sheet with your fax

•Submit expenses for multiple plan years on the same form

COVERAGE CODES – You must include a code on Section 2 of the form.

Medical codes		Dental codes
101	= co-payments	201	= co-payments
102	= over-the-counter medicines	202	= general dental (cleanings, X-rays, crowns, implants, dentures)
103	= prescriptions or prescription co-pays	203	= orthodontia
104	= general medical	204	= teeth whitening, bonding, veneers*
105	= chiropractic/physical therapy	205	= other dental
106	= in-patient hospital expense	Vision codes
107	= massage therapy	301	= co-payments
108	= counseling/psychotherapy	302	= over-the-counter vision (contact solutions, etc.)
109	= weight/itness management*	303	= general vision (exams, glasses, contact lenses)
110	= cosmetic surgery & procedures*	304	= non-prescription sunglasses*
111 = vitamins and supplements*		305	= vision correction surgery
112	= orthotics	Other codes
113	= electrolysis/hair restoration*	999	= other
114	= hearing aids	Note: *Indicates items that are generally not eligible healthcare expenses.
199	= other medical

IRS Tax Dependent Deinition: The Internal Revenue Code deines a “dependent” as a qualifying child who must reside with you for more than half the year and must not provide over half of his/her own support; this includes full-time students ages 19 through 24. A “qualifying relative” is an eligible individual if (1) you provide more than half of the individual’s support and (2) the individual is not a qualifying child of you or any other taxpayer. Based on recent changes made by the health care reform legislation (Patient Protection and Affordable Care Act (PPACA)), tax-free reimbursement of medical expenses incurred by adult children who have not reached age 26 by the end of the taxable year may be permitted. Please note that any questions regarding the status of an individual as either a qualifying child, a qualifying relative, or an adult child must be discussed with a qualiied tax advisor in conjunction with the provisions of your employer’s plan.

Questions? Need a list of eligible expenses? Visit myspendingaccount.adp.com or call ADP Customer Service at 1-800-678-6684.

Page #1

REIMBURSEMENT FORM – HEALTHCARE EXPENSES

Use only CAPITAL LETTERS, completely ﬁll in ovals,

and don’t use red ink.

FAX TO: 1-866-643-2219 TOLL FREE

For additional expenses, please use next page.

XHXCXRX

SECTION฀1:฀฀YOUR฀INFORMATION

SOCIAL SECURITY NUMBER OR EMPLOYEE ID (NO DASHES)

COMPANY NAME

EMPLOYEE LAST NAME

EMPLOYEE HOME ZIP CODE

FOR ADP ONLY

EMPLOYEE EMAIL		DAYTIME PHONE # (AREA CODE FIRST, NO DASHES)

SECTION฀2:฀฀YOUR฀HEALTHCARE฀EXPENSES

EXPENSE 1

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

PATIENT DATE OF BIRTH (MMDDYY )

COVERED BY INSURANCE?

YES	NO
EOB ATTACHED?
YES	NO

EXPENSE 2

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

PATIENT DATE OF BIRTH (MMDDYY )

COVERED BY INSURANCE?

YES	NO
EOB ATTACHED?
YES	NO

EXPENSE 3

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

COVERED BY INSURANCE?

YESNO

PATIENT DATE OF BIRTH (MMDDYY )

EOB ATTACHED?

YESNO

SECTION฀3:฀฀CERTIFICATION฀฀฀฀Please฀read฀Certiﬁcation฀Statement฀thoroughly฀before฀signing.

	I hereby certify that:
	• I have read and understand the instructions on page one.	FAX: 1-866-643-2219 Toll Free
	• The information contained within this form is correct.
	• I have not received reimbursement previously for these expenses from my Healthcare Account or any other plan	MAIL: ADP Spending Accounts
	and will not seek reimbursement by any other plan.
		PO Box 34700
	• Any expenses submitted on behalf of a dependent, qualifying relative or adult child are in accordance with the IRS
		Louisville, KY 40232
	Definitions of dependents, the guidelines for adult dependent children, or my employer's plan.
		PHONE: 1-800-678-6684
	I understand that:

•Reimbursement is not a guarantee that this payment is tax free.

•Healthcare expenses reimbursed through this account cannot be used as a deduction on my personal income tax return.

I hereby authorize release of payment through my Healthcare Account. I hereby authorize ADP or its representatives to obtain necessary information from all physicians, hospitals, medical service providers, pharmacists, employers, and all other agencies or organizations (this includes other insurers) to consider claim for reimbursement under

my Healthcare Account.

Date฀(MMDDYY)

฀

XHXCXRX

฀฀฀฀฀฀฀฀฀Employee฀Signature฀

฀

฀฀฀฀฀฀฀฀฀฀฀฀฀฀฀

USE AN ORIGINAL FORM (NOT A PHOTOCOPY)

Page฀#2

USE฀THIS฀PAGE฀FOR฀ADDITIONAL฀HEALTHCARE฀EXPENSES.

BHBABDB

SECTION฀4:฀฀YOUR฀INFORMATION฀(ABBREVIATED)

SOCIAL SECURITY NUMBER OR EMPLOYEE ID (NO DASHES)

EMPLOYEE LAST NAME

EMPLOYEE HOME ZIP CODE

SECTION฀5:฀฀YOUR฀ADDITIONAL฀HEALTHCARE฀EXPENSES

EXPENSE 4

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

PATIENT DATE OF BIRTH (MMDDYY )

COVERED BY INSURANCE?

YES	NO
EOB ATTACHED?
YES	NO

EXPENSE 5

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

PATIENT DATE OF BIRTH (MMDDYY )

COVERED BY INSURANCE?

YES	NO
EOB ATTACHED?
YES	NO

EXPENSE 6

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

PATIENT DATE OF BIRTH (MMDDYY )

COVERED BY INSURANCE?

YES	NO
EOB ATTACHED?
YES	NO

EXPENSE 7

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

PATIENT DATE OF BIRTH (MMDDYY )

COVERED BY INSURANCE?

YES	NO
EOB ATTACHED?
YES	NO

EXPENSE 8

DATES OF SERVICE (MMDDYY)

REQUESTED AMOUNT (DOLLARS . CENTS)

COVERAGE CODE (SEE PAGE 1)

FROM

COVERED BY INSURANCE?

YESNO

PATIENT DATE OF BIRTH (MMDDYY )

EOB ATTACHED?

YESNO

USE AN ORIGINAL FORM (NOT A PHOTOCOPY)

BHBABDB

Page฀#3

How to Edit Adp Fsa Claim Form Online for Free

It won't be hard to fill out myspendingaccount login with the help of our PDF editor. Here's how it is easy to instantly design your document.

Step 1: Click the button "Get Form Here".

Step 2: You're now able to alter myspendingaccount login. You possess lots of options thanks to our multifunctional toolbar - you can include, eliminate, or alter the content material, highlight the selected areas, as well as undertake various other commands.

For you to prepare the document, enter the details the platform will ask you to for each of the appropriate sections:

Type in the essential details in COVERAGE CODE SEE PAGE, FROM, EXPENSE, DATES OF SERVICE MMDDYY, COVERAGE CODE SEE PAGE, FROM, REQUESTED AMOUNT DOLLARS CENTS, COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH MMDDYY, EOB ATTACHED, YES, REQUESTED AMOUNT DOLLARS CENTS, COVERED BY INSURANCE, and YES area.

Remember to provide the required particulars in the I hereby certify that I have read, DateMMDDYY, XHXCXRX, EmployeeSignature, and USE AN ORIGINAL FORM NOT A field.

adp fsa claim form I hereby certify that I have read, DateMMDDYY, XHXCXRX, EmployeeSignature, and USE AN ORIGINAL FORM NOT A fields to insert

Inside of section SOCIAL SECURITY NUMBER OR EMPLOYEE, EMPLOYEE LAST NAME, EMPLOYEE HOME ZIP CODE, EXPENSE COVERAGE CODE SEE PAGE, DATES OF SERVICE MMDDYY, FROM, EXPENSE COVERAGE CODE SEE PAGE, DATES OF SERVICE MMDDYY, FROM, REQUESTED AMOUNT DOLLARS CENTS, COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH MMDDYY, EOB ATTACHED, and YES, state the rights and responsibilities.

Finalize the document by reviewing these fields: EXPENSE COVERAGE CODE SEE PAGE, DATES OF SERVICE MMDDYY, FROM, EXPENSE COVERAGE CODE SEE PAGE, DATES OF SERVICE MMDDYY, FROM, EXPENSE COVERAGE CODE SEE PAGE, DATES OF SERVICE MMDDYY, FROM, PATIENT DATE OF BIRTH MMDDYY, EOB ATTACHED, YES, REQUESTED AMOUNT DOLLARS CENTS, COVERED BY INSURANCE, and YES.

Step 3: As soon as you are done, press the "Done" button to export the PDF document.

Step 4: Ensure that you avoid forthcoming complications by producing no less than two duplicates of your file.

Adp Fsa Claim Form – Fill Out and Use This PDF

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