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

This document is used to submit claims for reimbursement for eligible health care and dependent care expenses incurred by employees under their flexible spending accounts.

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 or benefits administrator.
2. Start by filling out your personal information at the top of the form, including your name, address, employee ID, and contact details.
3. Indicate the type of claim you are submitting by checking the appropriate box (Health or Dependent Care).
4. Provide details of the expenses you are claiming, including the date of service, name of the provider, and the amount incurred.
5. Attach all required receipts and documentation that support your claim.
6. Review the form for any errors or missing information.
7. Sign and date the form to certify that the information provided is accurate and complete.
8. Submit the completed form and attached documentation to the designated claims address or upload it via the online claims portal, if available.

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

1. Employees who participate in a Health or Dependent Care Flexible Spending Account offered by their employer.
2. Individuals who have incurred eligible medical or dependent care expenses that they wish to reimburse from their FSA.

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 eligible health or dependent care expenses paid out of pocket. This form allows them to utilize funds set aside in a flexible spending account (FSA).

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

Employees who have enrolled in a Health or Dependent Care Flexible Spending Account and wish to seek reimbursement for qualified expenses must file this claim form.

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

To fill out the claim form, individuals should provide their personal information, specify the type of expense incurred, include the date of service, attach receipts or proof of payment, and sign the form before submitting it.

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

The purpose of the claim form is to facilitate the process of requesting refunds from an FSA for qualifying medical or dependent care expenses, thus ensuring employees can access the tax-free funds they have designated for such costs.

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

The form must include the employee's name, contact information, the type of expense, the date the service was provided, the total amount claimed, and copies of receipts or documentation supporting the claimed expenses.