The forms available here are those most often requested by our plan participants. There are three distinct types of forms for review: 1) General Information about FSA programs; 2) Comprehensive Dependent Day Care review; 3) FSA information, on key medical, dental, and vision expenses.
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FLEXIBLE SPENDING ACCOUNTS
CLAIMS AFFIDAVIT (FLEXIBLE SPENDING ACCOUNTS)
CLAIMS AFFIDAVIT (MEDICAL REIMBURSEMENT ACCOUNTS)
TRANSPORTATION REIMBURSEMENT PROGRAMS
DOCUMENTATION REQUIRED FOR REIMBURSEMENT
In order to be reimbursed for a FSA claim, the IRS requires 4 basic pieces of information:
1. DATE OF SERVICE
This information can be forwarded on an EOB (Explanation of Benefits from the insurance company) or a receipt completed by the provider of the services.
2. SERVICE RECEIVED
3. NAME OF CAREGIVER OR PROVIDER
4. COST OF SERVICE
DEPENDENT DAY CARE INFORMATION
DAY CARE TAX CREDIT AND FLEXIBLE SPENDING COMPARISON
Explains the differences using a Flexible Spending Account vs. the 1040 tax credit for dependent care.
DAY CARE ELIGIBILITY-PROVIDER INFORMATION
Outlines information on day care flexible spending account eligibility and requests plan participant to complete information about day care provider.
DAY CARE RECEIPT
May be used for submission for reimbursement by a plan participant for dependent day care expenses.
MEDICAL REIMBURSEMENT INFORMATION
Representative list of Medical/Dental/Vision expenses eligible for reimbursement found in Publication 502 of the Internal Revenue Code. Also includes services not reimbursable under IRC rules and regulations.
Review of Therapeutic Massage as reimbursable expense.
Review of reimbursement procedures for orthodontic treatment.
Form for documenting mileage incurred when traveling for medical treatment. Minimum mileage to qualify for reimbursement is 50 miles each way. Current reimbursement available is $0.15 per mile.
TRANSPORTATION REIMBURSEMENT INFORMATION
TRANSPORTATION REIMBURSEMENT AFFIDAVIT
If you are enrolling in the Transportation Reimbursement Program for the first time, or if this is a reenrollment, please complete this election form and forward it to Human Resources.
TRANSIT REIMBURSEMENT PLAN REQUEST FOR REIMBURSEMENT
When you submit claims for transportation reimbursement, please attach photocopies of your claims along with this Request for Reimbursement form.
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