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HEALTH CARE SPENDING ACCOUNT REIMBURSEMENT REQUEST FORM STREET ADDRESS PLAN YEAR SECTION A ENROLLED NAME SOCIAL SECURITY NUMBER DAYTIME PHONE AREA CODE NUMBER EXT. CITY STATE ZIP CODE SECTION B SUMMARY
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How to fill out NYS Flex Spending:

01
Gather necessary documentation such as receipts for eligible expenses, insurance information, and proof of dependent care expenses.
02
Access the NYS Flex Spending website or contact the program administrator to obtain the necessary forms.
03
Carefully review the instructions and guidelines provided with the forms.
04
Fill out the required personal and employment information accurately.
05
Determine the amount you want to contribute to your NYS Flex Spending account for the year and indicate it on the form.
06
Provide details about the eligible expenses you plan to use your Flex Spending funds for.
07
Submit the completed form along with any supporting documentation as instructed.
08
Keep a copy of the form and submitted documentation for your records.
09
Monitor your Flex Spending account throughout the year to track your expenses and remaining balance.

Who needs NYS Flex Spending:

01
Employees who have access to a Flexible Spending Account benefit through their employer.
02
Individuals who have eligible out-of-pocket medical, dental, or vision expenses.
03
Individuals who have dependent care expenses for dependents under the age of 13 or dependents incapable of self-care.
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NYS Flex Spending is a program that allows employees to set aside pre-tax dollars from their paycheck to pay for eligible medical expenses not covered by insurance.
Employees who participate in the NYS Flex Spending program are required to file for it.
To fill out NYS Flex Spending, employees need to complete the enrollment form provided by their employer and indicate the amount they wish to contribute from their pre-tax income.
The purpose of NYS Flex Spending is to help employees save money on eligible medical expenses by allowing them to use pre-tax dollars.
Employees must report the expenses incurred during the plan year to prove that the funds were used for eligible medical expenses.
The penalty for late filing of NYS Flex Spending is the forfeiture of any remaining funds in the account.
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