Get the free Dependent Care/ Health Care Reimbursement Account Plans Claim Form - calstate

This document serves as a claim form for participants of the Dependent Care Reimbursement Account (DCRA) and Health Care Reimbursement Account (HCRA), allowing for reimbursement of eligible dependent

How to fill out dependent care health care

How to fill out Dependent Care/ Health Care Reimbursement Account Plans Claim Form

1. Obtain the Dependent Care/Health Care Reimbursement Account Plans Claim Form from your HR department or company website.
2. Fill out your personal information, including your name, address, and employee ID.
3. Provide details about the dependent care or health care expenses, including the dates of service and the associated costs.
4. Attach all necessary documentation, such as receipts or invoices, which support your claim.
5. Sign and date the form at the designated areas to certify the information is accurate.
6. Submit the completed form and documentation to the appropriate claims processing address or via your company's claim submission platform.

Who needs Dependent Care/ Health Care Reimbursement Account Plans Claim Form?

1. Employees who have incurred dependent care expenses while working need to fill out the form to claim reimbursement.
2. Individuals participating in a health care reimbursement account that covers out-of-pocket medical expenses will also need this form.

People Also Ask about

How to submit receipts for dependent care FSA?

Log into your FSA account or use the unique account url provided by your employer. Click "Submit Receipt or Claim." Request "Pay My Provider" for healthcare or Dependent Care and follow the instructions.

How do you get reimbursed through a dependent care account?

Claims are processed within two business days, and you can choose to be reimbursed through direct deposit or by having a check mailed to you. There is no fee to you if you choose to have the money directly deposited into your bank account.

Does the IRS require receipts for FSA expenses?

Please save your receipts and other supporting documentation related to your HC FSA expenses and claims. The IRS may request itemized receipts to verify the eligibility of your expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

How to document dependent care FSA expenses?

When submitting a DCFSA claim, either have your dependent care provider certify the service by signing the claim form or provide an itemized statement from the dependent care provider that includes service dates, dependent's name, type of service, amount billed, and the provider's name and address along with a

How to submit receipt for dependent care FSA?

Dependent Care FSA Use the FSAFEDS app to have the dependent care provider certify the service by providing a signature on your mobile device. Have the dependent care provider certify the service by signing the completed claim form (PDF). Submit a claim (PDF) with an itemized statement from the dependent care provider.

How do I claim dependent care benefits?

To claim the credit, you (and your spouse, if you're married) must have income earned from a job and you must have paid for the care so that you could work or look for work. You can claim from 20% to 35% of your care expenses up to a maximum of $3,000 for one person, or $6,000 for two or more people (tax year 2024).

What is the downside to dependent care FSA?

Potential drawbacks of a Dependent Care FSA The funds you contribute don't roll over from plan year to year. If you and your partner's child care plans change, then you may be out that money. Not all employers offer Dependent Care FSA employee assistance program options.

Can you submit receipts to FSA?

Remember, to be accepted for a claim, you'll need one of the two accepted forms of paperwork: an itemized receipt, or an Explanation of Benefits (EOB) form (which is typically used for eligible medical services).

For pdfFiller’s FAQs

What is Dependent Care/ Health Care Reimbursement Account Plans Claim Form?

The Dependent Care/ Health Care Reimbursement Account Plans Claim Form is a document used by employees to request reimbursement for eligible dependent care or healthcare expenses incurred during the plan year.

Who is required to file Dependent Care/ Health Care Reimbursement Account Plans Claim Form?

Employees who have enrolled in a Dependent Care or Health Care Reimbursement Account plan and have incurred eligible expenses are required to file this claim form to receive reimbursements.

How to fill out Dependent Care/ Health Care Reimbursement Account Plans Claim Form?

To fill out the form, you must provide personal and account information, list the incurred expenses with dates and amounts, attach receipts or supporting documents, and sign the form to certify the accuracy of the claims.

What is the purpose of Dependent Care/ Health Care Reimbursement Account Plans Claim Form?

The purpose of the form is to facilitate the reimbursement process for employees by providing a standardized way to report and verify dependent care and healthcare expenses that are eligible under the plan.

What information must be reported on Dependent Care/ Health Care Reimbursement Account Plans Claim Form?

The form requires the reporting of personal details such as name and employee ID, details of the expenses including dates, amounts, and types of services, as well as any necessary documentation like receipts to support the claims.