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Information for Employees: Forms

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.

If you still have questions, click info@pzappaandassociates.com.

GENERAL INFORMATION

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
2. SERVICE RECEIVED
3. NAME OF CAREGIVER OR PROVIDER
4. COST 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.

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

MED LIST
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.

THERAPEUTIC MASSAGE
Review of Therapeutic Massage as reimbursable expense.

ORTHODONTIC REIMBURSEMENTS
Review of reimbursement procedures for orthodontic treatment.

MILEAGE DOCUMENT
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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