Fsa Claim Form PDF Details

If you are a full-time student and have a job, you may be eligible for the Federal Student Aid (FSA) program. The FSA program can provide you with money to help pay for your education. There are several different types of FSA funds available, including the Pell Grant, the work-study program, and federal student loans. To receive these funds, you must complete the Free Application for Federal Student Aid (FAFSA). The FAFSA is a form that asks for information about your financial situation. The form is used to determine your eligibility for FSA funds. In order to complete the FAFSA, you will need to know your Social Security number and date of birth. You will also need to know information about your parents’ finances, such as their income and assets. Completing the FAFSA can be a confusing process, but our website provides detailed instructions on how to do it. Follow these instructions carefully and you will be able to get the money that you need to pay for college.

QuestionAnswer
Form NameFsa Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfsa form, fsa form fillable, fsa1 form, fsa1

Form Preview Example

FLEXIBLE SPENDING ACCOUNT (FSA)

UnitedHealthcare

 

CLAIM FORM

FSA

FSA Customer Service Center

EL PASO TX 79998-1506

 

P.O. Box 981506

 

Phone: 800-842-2026 • FAX: 915-231-1709

FSA GRACE PERIOD

Toll Free FAX: 866-262-6354

All FSA claims with dates of service from January 1 through March 15 will first be paid from your previous year’s FSA balance (if funds are available) UNLESS you check the box in Part 2 or 3 labelled “Process claim only from current year funds.”

Reminders

Is your Employee Identification number (EIN) included on the form? (Your EIN is at the top of your biweekly earnings statement.)

Is your total requested amount included on the form?

Did you attach copies of your itemized documentation with your request? If needed, does your itemized bill show the date of service, a description of the service(s) provided, the patient name, and the fee charged? If covered by insurance, have you included an Explanation of Benefits (EOB) from you insurance plan? If not covered by insurance, have you noted this on your documentation?

Did you sign and date the bottom of this form? If not, your request will be denied.

Have you made copies of your request for your own personal records?

The following are examples of eligible supporting documentation that should be submitted with your request. A cancelled check is not adequate documentation.

Small receipts should be taped to a standard 8.5" x 11" sheet of paper and must be legible when scanned.

PART 2 - HEALTH CARE EXPENSES

Medical, Dental, Vision and Hearing Expenses

For expenses partially covered by your medical, dental or vision insurance plan, you must submit your Explanation of Benefits (EOB) statement with your completed claim form. If your EOB says that your dental or medical claim has been denied, and it does not describe the service or item in detail, also include an itemized statement from your dental or medical provider. This way, the FSA Customer Service Center knows the item or service was not denied by your insurance company because it was a cosmetic item or service (which cannot be paid through your FSA).

You may submit a Co-Pay receipt if this is your only expense.

For expenses not covered by your medical, dental or vision insurance plan, you must submit the following information:

• Name and Address of the provider

• Patient’s Name

• Dates of Service

• Type of Service

• Dollar amount charged

• Write “Not Covered by Insurance” on the receipt

PRIVACY ACT: Completing this form, which is used to process claims from your FSA account, is voluntary; however, without the information, we will be unable to process your request. Your copy of the PostalEASE FSA Worksheet includes a Privacy Act statement that lists the routine uses for which this information may be disclosed. If you are unable to locate your copy, you may obtain one from the Human Resources Shared Service Center (HRSSC). Authority: 39 U.S.C. 401, 1001, 1003, 1005; 5 U.S.C. 8339.

Over-the-Counter (OTC) Drugs and Medicines

When submitting a receipt for an over-the-counter drug or medicine, you must include a prescription from your health care provider, and a receipt that shows name of the over-the-counter drug or medicine, the price, and the date of purchase. Handwritten over-the counter item names on register receipts are unacceptable. The name of the item(s) and price(s) must be circled on the receipt. Receipts should be taped to a standard 8.5" x 11" inch piece of paper and must be legible when scanned. You do not need a prescription to be reimbursed for insulin.

Over-the-Counter (OTC) Supplies

When submitting a receipt for an over-the-counter supplies such as bandages, contact lens supplies and solutions, first aid supplies, and reading glasses, or for insulin, circle RX/OTC on the claim form. A printed receipt must include the name of the over-the-counter item, the price and the date of purchase. Handwritten over-the-counter items names on register receipts are unacceptable. The name of the item(s) and price(s) must be circled on the receipt. Receipts should be taped to a standard 8.5" x 11" sheet of blank paper. Receipts must be legible when scanned.

PART 3 - DEPENDENT CARE EXPENSES

Dependent Care Services

(1)You must complete the blocks under “Dependent Care Expenses.” (2) You must attach a receipt that shows the date(s), type and cost of the service. (3) Your provider must complete the “Dependent Care Provider’s Certification of Services Rendered” or all of the requested information, including the signature, must be included on the receipt that you attach.

Administered by UnitedHealthcare for the United States Postal Service

 

FSA1(NOV 2012)

(over)

FLEXIBLE SPENDING ACCOUNT CLAIM FORM

Please Read These Instructions Before Completing the FSA Claim Form

1. Employee must complete Part 1. Read the instructions for completing Parts 2 and 3 on the reverse of this form.

2. Read the Certification For Reimbursement, sign and date the form. Make a copy of this form and any documents you send for your records.

3. All reimbursement requests for a plan year made during the following year must be postmarked prior to the filing deadline, which is specified in your plan documents.

4. Mail (or FAX) the form to UnitedHealthcare, FSA Customer Service Center, P.O. Box 981506, El Paso TX, 79998-1506 • Phone: 800-842-2026 • 711 Relay via TRS • FAX: 915-231-1709

Toll Free FAX: 866-262-6354

PART 1 EMPLOYEE INFORMATION (Please Print)

EMPLOYEE NAME (Last and First)

EMPLOYEE IDENTIFICATION NUMBER

DATE OF BIRTH

 

DAYTIME TELEPHONE NO.

FSA

 

 

/

/

 

 

 

 

 

EMPLOYEE ADDRESS

 

FSA GROUP NUMBER

 

EMPLOYER NAME

 

 

1 4 1 2 4 5

 

U S P S

 

 

 

 

 

 

 

PART 2 HEALTH CARE EXPENSES (Please Print) Please place each expense on a separate line

PATIENT’S NAME

 

DATE(S) OF SERVICE

 

 

 

 

 

TYPE OF SERVICES

 

REQUEST

 

 

MM/DD/YYYY

 

 

 

Circle for each expense • MD=medical

 

AMOUNT

 

Date Started

Date Ended

RX/OTC=prescription/OTC • VS=vision • DN=dental •

HR=hearing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

MD

 

 

RX/OTC

 

VS

DN

HR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

MD

 

 

RX/OTC

 

VS

DN

HR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

MD

 

 

RX/OTC

 

VS

DN

HR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

MD

 

 

RX/OTC

 

VS

DN

HR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

MD

 

 

RX/OTC

 

VS

DN

HR

 

 

 

 

 

 

 

 

 

 

 

 

 

All claims dated January 1 through March 15 will first be paid from your previous

 

 

 

 

HEALTH CARE EXPENSES SUBTOTAL

$

year’s FSA balance (if funds are available) UNLESS you check the box below:

 

 

 

 

 

 

 

 

 

 

 

 

 

oProcess claim only from current year funds

 

 

 

 

 

 

 

 

 

 

 

PART 3 DEPENDENT CARE EXPENSES (Please Print)

Please place each expense on a separate line

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPENDENT’S NAME

 

DATE OF BIRTH

 

DATE(S) OF SERVICES

 

TYPE(S) OF SERVICES

REQUEST

 

 

 

 

 

 

Date Started

 

Date Ended

 

 

 

AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

All claims dated January 1 through March 15 will first be paid from your previous

 

 

 

DEPENDENT CARE EXPENSES SUBTOTAL

$

year’s FSA balance (if funds are available) UNLESS you check the box below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

oProcess claim only from current year funds

 

 

 

 

 

 

TOTAL REQUEST FOR WITHDRAWAL

$

 

 

 

 

 

 

 

 

 

 

 

 

Dependent Care Provider’s Certification of Services Rendered (Please Print)

 

 

 

 

 

 

 

 

I, the signer below, certify that the services listed in Part 3 above were rendered by me and charges incurred.

 

 

 

 

 

 

 

 

 

 

 

Dependent Care Provider’s Company Name and Signee Name:

 

Dependent Care Provider’s Address:

 

 

Dependent Care Provider’s Tax ID# or SSN:

Dependent Care Provider’s Signature:

CERTIFICATION FOR REIMBURSEMENT

I certify that the expenses for which I am requesting reimbursement from my Health Care FSA or Limited FSA as itemized above were incurred by me (and/or my spouse and/or eligible dependents) for medical care as permitted under the Health Care FSA or Limited FSA and have not been and will not be reimbursed by any other plan.

I certify that the expenses for which I am requesting reimbursement from my Dependent Care FSA, as itemized above, were incurred by me (and/or my spouse and/or eligible dependents) for dependent care as permitted under the Dependent Care FSA and have not been and will not be reimbursed by any other plan.

I understand that expenses reimbursed through the FSA program cannot be used to claim any Federal Income Tax deduction and/or credit. To the best of my knowledge and belief, my statements on this form are complete and true.

EMPLOYEE SIGNATURE:

DATE:

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW.