Get the free Flexible Spending Account OTC Claim Form

A form for employees to submit claims for reimbursement of eligible over-the-counter medical expenses through a Limited Health Flexible Spending Account (FSA).

How to fill out flexible spending account otc

How to fill out Flexible Spending Account OTC Claim Form

1. Obtain the Flexible Spending Account OTC Claim Form from your employer's benefits website or HR department.
2. Fill out your personal information at the top of the form, including your name, address, and employee ID.
3. Provide the date of service for the purchase of OTC items.
4. List each eligible OTC item purchased, including a brief description of the item, the cost, and the quantity.
5. Attach original receipts for each item purchased, ensuring they clearly show the date and amount.
6. Sign and date the form to certify that the information provided is accurate.
7. Submit the completed form along with the receipts to your Flexible Spending Account administrator via the method specified in the instructions (fax, mail, or online submission).

Who needs Flexible Spending Account OTC Claim Form?

1. Employees who participate in a Flexible Spending Account (FSA) plan.
2. Individuals who have purchased over-the-counter (OTC) health-related items using FSA funds.
3. Anyone who needs reimbursement for eligible OTC expenses incurred during the plan year.

People Also Ask about

What documentation is needed for a FSA claim?

Health Care FSA and Limited Expense Health Care FSA You must have a receipt or an explanation of benefits from your insurance carrier for each health care claim you submit against your account.

What documentation is needed for FSA reimbursement?

Using an FSA debit card will often mean you don't have to submit receipts to your administrator, but it's always a good idea to hold onto your receipts just in case they're needed for any reason.

What is not covered by a flexible spending account?

Please Note: The IRS does not allow Over-the-Counter (OTC) medicines or drugs to be purchased with Health Care FSA funds unless accompanied by a prescription and the prescription is filled by a pharmacist. If you have an OTC prescription, you can use your benefits card for these purchases.

Do I need to claim my FSA on my taxes?

Will I have to pay taxes on the money I contribute to health FSA and/or day care FSA? No. Money you put into an FSA is taken out of your salary before federal income taxes, Social Security and Medicare taxes and most state and local taxes are applied.

How do I get reimbursed from my flexible spending account?

With an FSA, you submit a claim to the FSA (through your employer) with proof of the medical expense and a statement that it hasn't been covered by your plan. Then, you'll get reimbursed for your costs. Ask your employer about how to use your specific FSA.

For pdfFiller’s FAQs

What is Flexible Spending Account OTC Claim Form?

The Flexible Spending Account OTC Claim Form is a document used to request reimbursement for eligible over-the-counter (OTC) medical expenses from a Flexible Spending Account (FSA).

Who is required to file Flexible Spending Account OTC Claim Form?

Employees who wish to be reimbursed for eligible over-the-counter medical expenses paid out of pocket using their Flexible Spending Account must file the OTC Claim Form.

How to fill out Flexible Spending Account OTC Claim Form?

To fill out the Flexible Spending Account OTC Claim Form, complete all required fields including your personal information, the details of the purchase, the amount being claimed, and attach any necessary receipts as proof of purchase.

What is the purpose of Flexible Spending Account OTC Claim Form?

The purpose of the Flexible Spending Account OTC Claim Form is to document and facilitate the reimbursement process for eligible OTC medical expenses incurred by FSA account holders.

What information must be reported on Flexible Spending Account OTC Claim Form?

The information that must be reported on the Flexible Spending Account OTC Claim Form includes the claimant's name, FSA account number, date of purchase, description of the expense, amount claimed, and any required receipts.