Get the free Health/Dependent Care Flexible Spending Accounts Claim Form

This document is used to submit claims for reimbursement from Health/Dependent Care Flexible Spending Accounts for eligible expenses incurred by an employee or their dependents.

How to fill out healthdependent care flexible spending

How to fill out Health/Dependent Care Flexible Spending Accounts Claim Form

1. Obtain the Health/Dependent Care Flexible Spending Accounts Claim Form from your employer's benefits portal or HR department.
2. Fill in your personal information at the top of the form, including your name, employee ID, and contact details.
3. Indicate the type of expenses you are submitting for reimbursement (healthcare or dependent care).
4. Attach the required documentation for each expense, such as receipts or invoices, ensuring they include the date, service description, and amount paid.
5. Complete any additional sections relevant to your claim, such as the provider's information for dependent care services.
6. Sign and date the form to verify the accuracy of the information provided.
7. Submit the completed form and attached documents to the designated claims processing address or through your employer's recommended submission method.

Who needs Health/Dependent Care Flexible Spending Accounts Claim Form?

1. Employees who participate in Health or Dependent Care Flexible Spending Accounts (FSAs) offered by their employer.
2. Individuals seeking reimbursement for qualifying medical expenses or dependent care costs incurred during the plan year.

People Also Ask about

What documentation do I need for dependent care FSA?

Start and end dates of service • Dependent's name and date of birth • Itemization of charges • Provider's name, address, and tax ID or Social Security number • Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

Do I need a receipt to claim dependent care FSA?

Supporting documentation for your claim should be an itemized statement from the dependent care provider that includes: service date(s), the dependent's name, the type of service, amount billed, and provider's name and address. You may not submit a canceled check as supporting documentation.

How do I report dependent care FSA on W-2?

Start and end dates of service • Dependent's name and date of birth • Itemization of charges • Provider's name, address, and tax ID or Social Security number • Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

Is there a tax form for dependent care in FSA?

You're receiving a tax benefit because under the plan, you're not paying taxes on the money set aside to pay for the dependent care expenses. You must complete and attach Form 2441, Child and Dependent Care Expenses to your tax return.

How to submit a claim for dependent care in 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 to submit claim for dependent care in FSA?

Supporting documentation for your claim should be an itemized statement from the dependent care provider that includes: service date(s), the dependent's name, the type of service, amount billed, and provider's name and address. You may not submit a canceled check as supporting documentation.

For pdfFiller’s FAQs

What is Health/Dependent Care Flexible Spending Accounts Claim Form?

The Health/Dependent Care Flexible Spending Accounts Claim Form is a document used by employees to request reimbursement for qualified medical or dependent care expenses incurred during the plan year.

Who is required to file Health/Dependent Care Flexible Spending Accounts Claim Form?

Employees who participate in a Health/Dependent Care Flexible Spending Account and seek reimbursement for eligible expenses must file this claim form.

How to fill out Health/Dependent Care Flexible Spending Accounts Claim Form?

To fill out the form, employees need to provide their personal information, details about the expenses being claimed, attach any required receipts or documentation, and sign and date the form before submitting it for reimbursement.

What is the purpose of Health/Dependent Care Flexible Spending Accounts Claim Form?

The purpose of the claim form is to facilitate the reimbursement process for eligible health and dependent care expenses, ensuring employees can access their Flexible Spending Account funds.

What information must be reported on Health/Dependent Care Flexible Spending Accounts Claim Form?

The form requires the employee's name, the type of expenses being claimed, the date of service, the amount being claimed, and documentation such as receipts or invoices for the expenses.