Adp Fsa Claim Form – Fill Out and Use This PDF

The Adp Fsa Claim Form is a critical form for anyone who works in the finance sector. The company uses it to determine which employees are eligible for benefits.

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Adp Fsa Claim Form PDF Details

The American Dream is a term that has been used for decades to define the idea of living out one's life in freedom, happiness, and prosperity. The phrase often encompasses ambitions within the United States. This blog post will explore what an Fsa Claim Form is, how it works, and why you might need to submit one. The Adp Fsa Claim Form can be completed by individuals who are filing for Supplemental Security Income (SSI) due to disability or blindness. It may also be filed by individuals who are applying for SSI benefits because they've reached retirement age but have not yet applied for Social Security Retirement Benefits (i.e., they're still working).

In the listing, there is some information regarding the adp fsa claim form. Before you decide to fill out the form, it is worth checking more about it.

Question	Answer
Form Name	Adp Fsa Claim Form
Form Length	3 pages
Fillable?	Yes
Fillable fields	254
Avg. time to fill out	25 min 48 sec
Other names	myspendingaccount adp customer service, myspendingaccount adp com, adp flexible spending accounts, myspendingaccount login

12

Form Preview Example

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

$

.

TO

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

$

.

TO

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

TO

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

$

.

TO

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

$

.

TO

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

$

.

TO

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

$

.

TO

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

TO

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

You can easily complete documents with the help of our PDF editor. Updating the adp fsa file is a breeze in case you keep to the next steps:

Step 1: Search for the button "Get Form Here" on this webpage and click it.

Step 2: Once you've got entered the editing page adp fsa, you will be able to discover all of the functions available for the document at the top menu.

The next parts are what you are going to complete to obtain the finished PDF form.

adp flexible spending accounts empty spaces to fill out

Fill out the EXPENSE 3 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, PATIENT DATE OF BIRTH MM, DD, YY ), E, OB ATTACHED, YES, REQUESTED AMOUNT (DOLLARS , COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH MM, DD, YY ), E, OB ATTACHED, YES, I hereby certify that: • I have, and FAX: 1, 866, 643, 2219 Toll Free fields with any data that can be asked by the software.

EXPENSE 3 COVERAGE CODE (SEE PAGE, DATES OF SERVICE (MMDDYY) FROM, PATIENT DATE OF BIRTH (MMDDYY ), EOB ATTACHED, YES, REQUESTED AMOUNT (DOLLARS , COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH (MMDDYY ), EOB ATTACHED, YES, I hereby certify that: • I have, and FAX: 1-866-643-2219 Toll Free in adp flexible spending accounts

Write down the crucial information in I hereby certify that: • I have, Date, MM, DD, YY Employee, Signature USE AN ORIGINAL FORM (NOT A, Page, 2 and X, HX, CX, R, X area.

part 3 to filling out adp flexible spending accounts

The EXPENSE 4 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, EXPENSE 5 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, EXPENSE 6 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, EXPENSE 7 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, REQUESTED AMOUNT (DOLLARS , COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH MM, DD, YY ), E, OB ATTACHED, YES, and REQUESTED AMOUNT (DOLLARS segment should be applied to write down the rights or obligations of both parties.

stage 4 to entering details in adp flexible spending accounts

Finalize by checking the next sections and typing in the appropriate details: EXPENSE 7 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, EXPENSE 8 COVERAGE CODE (SEE PAGE, DATES OF SERVICE MM, DD, YY FROM, YES, PATIENT DATE OF BIRTH MM, DD, YY ), E, OB ATTACHED, YES, REQUESTED AMOUNT (DOLLARS , COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH MM, DD, YY ), E, OB ATTACHED, YES, and USE AN ORIGINAL FORM (NOT A.

adp flexible spending accounts EXPENSE 7 COVERAGE CODE (SEE PAGE, DATES OF SERVICE (MMDDYY) FROM, EXPENSE 8 COVERAGE CODE (SEE PAGE, DATES OF SERVICE (MMDDYY) FROM, YES, PATIENT DATE OF BIRTH (MMDDYY ), EOB ATTACHED, YES, REQUESTED AMOUNT (DOLLARS , COVERED BY INSURANCE, YES, PATIENT DATE OF BIRTH (MMDDYY ), EOB ATTACHED, YES, and USE AN ORIGINAL FORM (NOT A fields to fill out

Step 3: If you're done, click the "Done" button to transfer the PDF file.

Step 4: To prevent yourself from any kind of problems in the long run, you should generate at the very least a couple of copies of the document.

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