Get the free Health & Dependent Care Reimbursement Claim Form - eap ucop

This form is to be used by employees of the University of California to request reimbursement for health care and dependent care expenses through their Flexible Spending Account. It includes sections

How to fill out health dependent care reimbursement

How to fill out Health & Dependent Care Reimbursement Claim Form

1. Obtain the Health & Dependent Care Reimbursement Claim Form from your employer or the benefits administration website.
2. Read the instructions carefully to understand what expenses are eligible for reimbursement.
3. Fill out your personal information at the top of the form, including your name, address, and employee ID.
4. List each eligible expense in the correct section of the form, including the date of service, the provider's name, the amount incurred, and a brief description of the service.
5. Attach supporting documentation for each expense, such as receipts or invoices showing the service provided and the date.
6. Sign and date the form to certify that the information provided is accurate.
7. Submit the completed claim form and attached documents to the designated claims processing department or email address, as instructed.

Who needs Health & Dependent Care Reimbursement Claim Form?

1. Employees who have dependent care expenses, such as childcare or eldercare, that qualify for reimbursement under eligible employer-sponsored benefit plans.
2. Individuals enrolled in a flexible spending account (FSA) related to health or dependent care.

People Also Ask about

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 documentation is required for FSA reimbursement?

Q: How long does it take to receive a reimbursement check from my Flexible Spending Accounts (FSA)? Generally, you receive your Healthcare FSA or Dependent Care FSA by direct deposit or check within two weeks after the claim and required documentation are received, approved, and processed.

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.

What is the form for dependent care benefit?

Form 2441 is used to claim the Child and Dependent Care Credit, which is available to those who pay someone to care for dependent children under 13, disabled spouses, or other dependents who cannot mentally or physically care for themselves.

How do I get reimbursed from my FSA?

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.

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 do I get reimbursed for FSA eligible expenses?

Employers may make contributions to your FSA, but they aren't required to. 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.

For pdfFiller’s FAQs

What is Health & Dependent Care Reimbursement Claim Form?

The Health & Dependent Care Reimbursement Claim Form is a document used by employees to request reimbursement for eligible health and dependent care expenses incurred during the year.

Who is required to file Health & Dependent Care Reimbursement Claim Form?

Employees who have incurred eligible health and dependent care expenses and wish to be reimbursed through their employer's benefits plan are required to file this form.

How to fill out Health & Dependent Care Reimbursement Claim Form?

To fill out the form, you need to provide your personal information, details of the expenses incurred, attach relevant documentation such as receipts, and sign the form before submitting it to your benefits administrator.

What is the purpose of Health & Dependent Care Reimbursement Claim Form?

The purpose of the form is to allow employees to reclaim money spent on qualified health and dependent care expenses, thereby helping them manage costs related to healthcare and childcare.

What information must be reported on Health & Dependent Care Reimbursement Claim Form?

The form must report information such as the employee's name, contact details, expense amounts, the nature of the expenses, the dates of service, and any related documentation verifying the expenses.