Vita Flex Fsa Medical Claim Form PDF Details

Vita Flex Fsa Medical Claim Form is located on the FSA Store website. It is a PDF document that can be filled out on your computer and then printed. There are also instructions on how to fill out the form, which you can download as a PDF or view as a video. The form is eight pages long, and there are five sections: personal information, health insurance information, current conditions, treatments received, and prescriptions. You will need to provide your name, address, Social Security number, date of birth, health insurance company name and policy number, group number (if applicable), and physician's contact information. In the "current conditions" section you will list any medical conditions for which you have treatments or prescriptions.

Here is the information concerning the form you were in search of to fill out. It can tell you the time it will require to complete vita flex fsa medical claim form, exactly what parts you will have to fill in and some other specific facts.<

QuestionAnswer
Form NameVita Flex Fsa Medical Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesvitaflex hsa login, vitaflex form, vitaflex hsa forms, vita flex claim form

Form Preview Example

VitaFlex

Dependent Care Flexible Spending Account

Expense Claim Form

Employee Data

Company Name:

Employee Name:

Employee Social Security or ID Number:

Dependent Information (complete once per year for each dependent)

Full Name

Date of Birth

Relationship to Employee

Provider Receipt

Additional receipts are not necessary if the below section is completed by the dependent care provider. In lieu of the child care provider’s signature below, you may submit a receipt from the provider to substantiate this claim.

 

Provider Name:

 

 

Provider Tax ID Number:

 

 

 

 

 

 

 

Explanation of Care Provided:

 

 

 

 

 

 

 

 

 

 

Name of Dependent

Dates of Care

 

 

Charge for Care

 

 

 

 

 

 

 

From:

To:

$

 

 

 

 

 

 

 

From:

To:

$

 

 

 

 

 

 

 

From:

To:

$

 

 

 

 

 

 

 

 

 

 

Total

$

 

 

 

 

 

 

I certify that dependent care was provided to above referenced dependents on the dates indicated. The charges for care reflect dependent care for the dates indicated.

Date

Provider Signature

Printed Provider Name

Verification

To the best of my knowledge and belief, the statements in this dependent care expense claim form are complete and true. I certify these claims are for valid dependent care expenses provided on the dates indicated and that these expenses were incurred while I was actively participating in the VitaFlex Dependent Care Reimbursement Plan, and that these expenses are incurred by an eligible participant under the plan (either myself as the eligible employee or an eligible dependent according to the guidelines of the plan). These expenses have not been reimbursed under the VitaFlex plan previously nor have they been reimbursed under any other dependent care plan. Additionally, I do not expect any of these expenses to be reimbursable elsewhere in the future. I understand that these expenses may not be used to claim any federal income tax deduction or credit. I understand that I alone am responsible for the sufficiency, accuracy and validity of all information relating to this claim. If any claim for reimbursement is not an eligible expense under the plan, I will be responsible for payment of all related liabilities, including federal and state income taxes and any applicable penalties resulting from improper reimbursement from the plan.

Date

Employee Signature

New Phone/Address (Complete Only if Needed)

New Preferred Phone Number:

(

)

New E-mail Address:

New Home Address:

A photocopy of this form may be used if additional copies are needed.

For fastest service, fax claims to 650-964-FLEX (3539) or e-mail claims to claims@vitamail.com.

Watch Vita Flex Fsa Medical Claim Form Video Instruction

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