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Request for Reimbursement FSA/DCA CLAIM FORM (10/2011) Employer Name: Employee Name: Address: LAST FIRST MI SS# Phone: STREET CITY STATE
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01
Start by downloading the pbs-manual-claim-fsa-dca-10-11doc form from the official website or request a copy from your employer.
02
Take your time to thoroughly read the instructions provided with the form.
03
Gather all the necessary documents and information required to fill out the form. This may include medical receipts, invoices, or any other supporting documents.
04
Begin by filling out your personal details such as your name, contact information, and social security number.
05
Proceed to provide information about your healthcare provider, including their name, address, and contact details.
06
Carefully review each section of the form and provide accurate and complete information. Take note of any specific instructions or requirements mentioned in the form.
07
If applicable, provide details about your dependent(s) who are covered under the healthcare plan.
08
Clearly indicate the type of expenses being claimed, such as medical, dental, or vision, and provide a detailed description of each expense.
09
Attach all the relevant supporting documents, ensuring they are organized and labeled correctly. Make copies for your records if necessary.
10
Carefully review the completed form and make any corrections if required.
11
Sign and date the form where indicated.
12
Submit the filled-out form and supporting documents to the appropriate department or address as specified in the instructions.
13
Retain a copy of the submitted form and supporting documents for your records.

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Anyone who wishes to make a claim for eligible healthcare expenses needs the pbs-manual-claim-fsa-dca-10-11doc form.
02
Employers may provide this form to their employees who have a flexible spending account (FSA) or dependent care account (DCA) as part of their benefits package.
03
Individuals who have incurred healthcare expenses and are eligible for reimbursement from their FSA or DCA can also use this form to submit their claims.
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It is a form used to claim reimbursement for flexible spending accounts and dependent care accounts.
Employees who have expenses eligible for reimbursement from their flexible spending accounts or dependent care accounts.
The form should be filled out with the employee's personal information, details of the expenses incurred, and any supporting documentation.
The purpose is to request reimbursement for eligible expenses incurred by the employee.
Employee's personal information, details of expenses incurred, and any supporting documentation.
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