Uniaccount Fsa Form PDF Details

Navigating the complexities of the Uniaccount Flexible Spending Account (FSA) claim form requires an understanding of its various components, designed to provide individuals with an avenue to manage their healthcare and dependent care expenses more effectively. This form is facilitated by customer service numbers and addresses for both mailing and faxing, ensuring accessibility for users to seek assistance or submit their claims conveniently. Firstly, it collects employee information, including basic personal details alongside employer data, highlighting an initial step towards claim submission. Thereafter, the form delves into the specifics of dependent care information, where it's essential for the claimant to furnish details about the dependent, the care provided, and associated costs, ensuring these expenses qualify under the established guidelines. Moreover, the form meticulously outlines the requirements for health care claims, stipulating the necessity of including an Explanation of Benefits or a detailed account of the expenses if the former isn't available. An important note made is the change effective from January 1, 2011, regarding over-the-counter medicines or drugs, which mandates having a prescription for reimbursement eligibility. Additionally, signatories must certify their claims' authenticity and compliance with tax implications. The form concludes with insightful summaries of what expenses might be eligible for reimbursement under both Health and Dependent Care FSAs, providing a useful reference to users for maximizing their benefits in adherence to IRS and other regulatory interpretations. Emphasizing the importance of preserving copies of the form and attachments for personal records, the document frames a comprehensive approach towards managing healthcare and dependent care expenses through FSAs.

QuestionAnswer
Form NameUniaccount Fsa Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesuniaccount flexible spending claim form, uniaccount fsa, uniaccount anthem, you uniaccount fsa create

Form Preview Example

FLEXIBLE SPENDING ACCOUNTS CLAIM FORM

Customer Service Voice:

888-209-7976

P. O. Box 4381 Woodland Hills Ca 91365-4381

Customer Service Fax:

818-234-4730

 

 

SECTION A.

 

 

 

EMPLOYEE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

Employer’s Street Address

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member Identification Number

 

Employee’s Last Name

First Name

 

 

MI

Date Of Birth

Gender

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

Check here if the health

Check here if

 

Employee’s Street Address

 

City

 

State

Zip

 

 

care expenses below

you have a new

 

 

 

 

 

 

 

 

 

 

are also covered by

address?

 

 

 

 

 

 

 

 

 

 

 

another health care

 

 

 

 

 

 

 

 

 

 

 

 

plan?

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number(s):

Day (

)

-

ext

Evenings

(

)

-

ext

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you need additional claim forms, please

 

 

Mail

E-mail address:

 

 

 

 

 

 

 

indicate how you would like to receive them:

 

 

 

 

 

 

 

 

SECTION B.DEPENDENT CARE INFORMATION

INSTRUCTIONS:

1.Complete this Section, which includes the name of the dependent, the date(s) care was provided, the amount paid, the dependent care provider’s name address and Tax I.D. or Social Security number. Provider’s signature required OR you must attach a written statement from the dependent care provider. Dependent children must be under age 13 to qualify for reimbursement. See additional eligibility rules on reverse.

2.If care is provided in your home, complete this section and itemize the following on a separate piece of paper:

Room and board; transportation; other specific expenses incurred by the provider related to the care of your dependent(s). Wages paid to the provider; FICA and FUTA taxes

3.Keep a copy of this form and attached supporting documentation for your records.

Name of Provider (Please Print or Type)

Signature of Provider

Tax ID No.

Street Address of Provider

Dependent’s Name

Dependent’s Name

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

Date of Birth

Relationship To Employee

Dependent Care Services Rendered

Amount:

 

 

 

From:

To:

 

 

 

 

 

 

 

Date of Birth

Relationship To Employee

Dependent Care Services Rendered

Amount:

 

 

 

From:

To:

 

 

 

 

 

 

 

 

 

 

 

SECTION C.

HEALTH CARE INFORMATION

 

 

 

 

 

 

 

INSTRUCTIONS:

1.Attach Explanation of Benefits (EOB) showing amounts you are obligated to pay. If you do not have an EOB, please provide an explanation in the “Explanation”

Column below and attach an Itemized bill. Note: Itemized Bills contain the provider’s name, the date of service, the amount charged, and a description of the service provided. Credit card receipts, balance forward statements and canceled checks are not considered itemized bills. Please include no more than 6 receipts or EOBs per form.

2.Mail or fax this form and supporting documentation to the address or fax number listed at the top this form.

3.Keep a copy of this form and attached supporting documentation for your records.

* NOTE: Effective January 1, 2011, the cost of an over-the-counter (OTC) medicine or drug cannot be reimbursed unless a prescription is obtained.

Date of Service (From/To)

Amount

Self/Dependent Name

Provider/Explanation

1.-

2.-

3.-

4.-

5.-

6.-

Total

I certify that either myself and/or my eligible dependents have incurred the expenses for which reimbursement is claimed from either the Health or Dependent Care Reimbursement Accounts and that I have not and will not deduct these expenses on my individual income tax return. I further certify this health care expense has not been reimbursed or is not reimbursable under any other Employer sponsored health care plan and that expenses have been paid.

REV 9/2010

receives a fee, grant or payment for providing these services to any individual; and complies with all applicable state an local laws.
provides care for more than six individuals (other than those who reside at the facility);

SIGNATURE

DATE

\HEALTH CARE EXPENSES

The following is a summary of common expenses that may be eligible for reimbursement through a Health Flexible Spending Account. The information that follows is compiled from publications issued by the Internal Revenue service. The information below is meant to serve as a guide only and is subject to the interpretation of the law by the Internal Revenue Service, that of other government agencies, and changes to the law. All expenses must be incurred during the plan year in which contributions are made and while actively enrolled as defined by your employer in the Health Flexible Spending Account in order to be reimbursable.

Acupuncture Performed by a licensed practitioner

Optometrist services within scope of license

Services rendered by a treatment center for Alcoholism/Drug

Orthodontia for non cosmetic reasons

Dependency

Oxygen

Artificial Limbs

Physical Exams that are non employment related

Artificial Teeth

Physical therapy

Birth control pills and devices prescribed by a physician

Psychiatric care

Braille books and magazines

Psychoanalysis

Breast Reduction when physician substantiates medical necessity

Psychologist services

Car controls and other special equipment for the handicapped

Schools special schooling to relieve handicap

Chair - The cost of a reclining chair prescribed by a

Smoking-cessation programs and prescribed drugs to

physician to alleviate a heart, back or other condition

alleviate nicotine withdrawal

Chiropractors Services within scope of license

Sterilization

Christian Science practitioners

Surgery including experimental

Contact Lenses and solutions

Syringes, needles, and injections

Crutches Purchase or rental

Telephone special equipment for hearing impaired

Deductibles and co-payment AND balance not paid by

Television audio display equipment for hearing impaired

insurance

Therapy physical or occupational therapy

Dental fees and X-rays, fillings, braces, extraction, etc.

Transplants

Eyeglasses, lenses, frames, exams

Transportation primarily for and essential to medical care as defined

Eye surgery to correct vision, such as Radial Keratomy and

below:

Photorefractive Keratectomy

*

bus, taxi, train, or plane fare or ambulance service

Fertility treatment including in-vitro fertilization

*

car expenses, such as gasoline and oil;

Founder’s Monthly lump-sum fee to a retirement home

*

parking fees and tolls;

(covers portion specifically for medical care)

*

transportation expenses for a parent who must accompany a

Guide dog purchased by the visually or hearing impaired

 

child who needs medical care;

Halfway house care to help individual adjust from life in

*

transportation expenses for a nurse or other person who can

mental hospital to community living

 

give injections, medications, or other treatment required by a

Health care equipment not for general use articles for

 

patient who is traveling to get medical care and is unable to

Furniture, household items, or appliances

 

travel alone;

Hearing aids and Hearing Aid Batteries

*

transportation expenses to see a mentally ill dependent if the

Hospitalization, Including private room coverage

 

visits are recommended as part of treatment

Hypnosis for treatment of illness

Instead of actual expenses it is acceptable to use a flat rate

Insulin Medication

provided by the IRS for each mile a car is used for medical

Learning disability tutoring by licensed school or therapist

purposes.

for child with severe learning disability

Vaccinations and immunizations

Lifetime care advance payment to private institution for

Vitamins and mineral supplements, only available by prescription

care of mentally or physically handicapped patient

and prescribed by a physician to treat a specific medical condition

Medicines & Drugs

Wheelchairs

DEPENDENT CARE EXPENSES

The following is a summary of the types of expenses that may be eligible for reimbursement through a Dependent Care Flexible Spending Account. The information that follows is compiled from publications of the Internal Revenue Service. The information below is meant to serve as a guide only and is subject to the interpretation of the law

by the Internal Revenue Service, that of other government agencies, and changes to the law. Dependent care FSAs essentially operate in the same way as health FSAs, except for one important exception: The entire year’s contribution is not immediately available in a Dependent Care FSA. All expenses must be incurred during the plan

year in which contributions are made and while actively enrolled as defined by your employer in the Dependent Care Flexible Spending Account in order to be reimbursable.

Eligible Dependent: An eligible dependent is defined as any person who can be claimed by an employee as a dependent for federal tax purposes (under Section 151 (c ) of the tax code) and who:

is under age 13; or

requires full-time care because of physical or mental incapacity (for example, a disabled spouse or parent); or

is the spouse of the employee and is physically or mentally incapable of care for himself or herself.

Expenses for care provided outside a taxpayer’s home may be claimed only for dependents under age 13 or other dependents who regularly spend at least eight hours per day in the taxpayer’s home. Also, expenses incurred during a plan year after a child attains age 13 are not reimbursable.

You may not claim dependent care expenses which exceed the lesser of: The fixed dollar maximum of your plan; your earned income; or (if you are married) your spouse's earned income. If your spouse is either a full-time student or is incapable of self-care, your spouse will be deemed to have qualifying earnings for each month he or she is a full-time student or incapacitated. The amount of deemed earnings will be: $200 a month, if you provide care for one Qualifying Individual, or, $400 a month, if you provide care for more than one Qualifying Individual.

Qualified care provider: Payments for dependent care services provided by dependents of either the taxpayer or the taxpayer’s spouse, or to a child of the taxpayer who is under age 19, do not qualify.

Expensesincurred for care at a child care center are qualified only if the center:

Qualified expenses: A qualified expense must enable the employee (and spouse, if married) to be gainfully employed or to look for gainful employment. Qualified expenses only include the cost of services for the dependent’s well-being and safety

Schooling - Educational expenses incurred for a child below kindergarten level qualify as eligible expenses.

Camps and baby-sitting: Summer day camp expenses qualify as eligible expenses, but overnight camp expenses do not. Generally, evening baby-sitting would not qualify as an eligible expense unless a single parent or both married parents work in the evening.

Transportation, entertainment and food: The cost of transportation, entertainment, food or clothing cannot be reimbursed unless such items are incidental and cannot be separated from the cost of the care provided. This means that the cost of getting a child or other qualifying dependent from home to a care provider, or from school to a care provider is not a qualified expense. Public transportation fares (e.g., travel by bus, subway or taxi) do not qualify as an expense nor are any costs associated with operating a private car. This rule applies to providers as well as dependents; that is, transportation costs associated with bringing a care provider to an employee’s home are not qualified expenses.

Household expenses: Expenses paid for household services qualify if they: (1) pertain to services provided in the employee’s home that are “ordinary and usual” and “necessary to the maintenance of the household” (such as a maid, housekeeper or cook); and (2) are attributable at least in part to the care of the

qualifying individual. The services of a gardener or chauffeur, for example, would not qualify as eligible expenses.

FSACLMFRM:10/01/2001

Payroll taxes: Payment of payroll taxes by an employee in connection with compensation paid to a service provider is a qualified expense. These taxes include Social Security (FICA)/Medicare tax, federal unemployment tax (FUTA) or similar state payroll taxes.

FSACLMFRM:10/01/2001