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Please complete this form to request reimbursement of expenses incurred by you and/or eligible dependents. Itemized documentation of each expense must be provided.
To qualify for reimbursement, expenses must be incurred during the Plan Year for which you are requesting reimbursement. 1. Flexible Spending Account – Health Care Reimbursement (FSA): may used for medical expenses incurred by you or your family that are not covered by another health plan. Eligible items include but are not limited to:
FSA/HRA Reimbursement Form Flex Card User Guide FSA Election ... My Flex Account Mobile App Overview. CrossTech Overview. Limited Purpose FSA Overview. Dependent Care FSA Flyer. Dependent Care FSA FAQ . Spanish Materials . Common FSA Eligible Expenses List (Spanish)
Make sure to sign and date this form before submitting it for reimbursement. Don’t forget to check out MyFlexDollars.com – your one-stop FSA resource. Log in today to view your account balance, check the status of a claim, file a claim, and more!
Manual Claim Reimbursement Process. CrossTech Overview. My Flex Account Mobile App Overview . Spanish Materials . FSA/HRA Reimbursement Form (Spanish) CrossTech Authorization Form (Spanish) CrossTech Overview (Spanish) Flex Card Overview (Spanish) Myflexaccount.com Overview (Spanish)
You must complete an FSA Request for Reimbursement Form for each Health or Dependent Care FSA claim you file. You may also submit your claim data online. When submitting your claim online, you’ll have the opportunity to either upload scanned receipts or print a fax cover page to fax in with your documentation.
Now you can file claims through My Flex Account Mobile in just a few simple steps. Note: If your employer has set a minimum reimbursement amount, you will not receive reimbursement until the minimum amount has been met
