Get the free FSA CoreSource Claim Form 2012.doc - stjude

This document serves as a sponsorship request for the St. Jude Trike-A-Thon program, where participants learn riding-toy safety and raise funds for St. Jude Children’s Research Hospital.

How to fill out fsa coresource claim form

How to fill out an FSA Caresource claim form:

1. Obtain the claim form: Start by obtaining the FSA Caresource claim form. This can typically be done by requesting it from your employer or by downloading it from the FSA Caresource website.
2. Personal information: Fill out the personal information section of the form. This typically includes your name, address, phone number, Social Security number, and FSA Caresource account number. Make sure to double-check the accuracy of this information to avoid any processing delays.
3. Provider information: Provide the necessary details about the healthcare provider or facility where you received the services or products you are claiming for. This usually includes the name, address, and phone number of the provider.
4. Dates of service: Specify the dates when you received the services or purchased the products covered by your FSA Caresource account. This helps in ensuring that the claim is within the eligible time frame.
5. Description of services/items: Provide a detailed description of the services or items for which you are making a claim. Include any relevant codes, such as CPT codes for medical services or UPC codes for eligible retail products.
6. Cost information: Indicate the cost of each service or item being claimed. This may include any applicable copayments, deductibles, or coinsurance amounts. Attach any supporting documentation, such as receipts or itemized bills, to substantiate the expenses incurred.
7. Sign and date: Remember to sign and date the completed claim form. This acknowledges that the information provided is accurate to the best of your knowledge.

Who needs an FSA Caresource claim form:

1. Employees with a Flexible Spending Account (FSA): The FSA Caresource claim form is typically required by individuals who have an FSA through their employer as part of their employee benefits package.
2. Individuals seeking reimbursement: If you have paid for eligible medical expenses or qualified retail products out-of-pocket, you may need to fill out an FSA Caresource claim form to request reimbursement from your FSA account.
3. Dependents or family members: The FSA Caresource claim form may also be needed for dependents or eligible family members covered under your FSA plan. This is especially relevant if they have incurred eligible healthcare expenses or purchased qualifying products.

Note: It is important to review the specific guidelines and requirements of your FSA Caresource plan, as they may vary depending on your employer and the plan you have chosen.

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