Fsa Reimbursement Form - Healthtrust
ADVERTISEMENT
1
2Healthcare Flexible Spending Account
Dependent Care Reimbursement Account
REIMBURSEMENT FORM
(Please see instructions on reverse side)
EMPLOYEE INFORMATION
Employer _______________________________________________ Plan Year ________________________________
Employee Name ____________________________________________________________________________________
Address ___________________________________________________________________________________________
Street
Town/City
State
Zip
PART 1 - HEALTHCARE FSA EXPENSES
Relationship
Name of Individual
Date Service
Description of Service
Amount
(e.g., spouse,
Receiving Service
Provided
(name of provider)
son, daughter)
Healthcare Expenses Subtotal $
PART 2 - DEPENDENT CARE REIMBURSEMENT ACCOUNT EXPENSES
Date Service
Provider Name
Dependent’s Name
Date of Birth
Amount
Provided
(include Tax ID#)
Dependent Care Expenses Subtotal $
TOTAL: __________
You may request that your dependent care provider complete the below Dependent Care Provider’s Certification, OR attach a copy of a
receipt that includes the provider’s name, dates of service, service rendered, and total charge.
DEPENDENT CARE PROVIDER’S CERTIFICATION OF SERVICES RENDERED
I, the signer below, certify that the services listed in Part 2 were rendered by me and charges incurred have been paid for.
Provider’s Name:
Provider’s Address:
Provider’s Tax ID#:
Provider’s Signature:
Date:
EMPLOYEE CERTIFICATION
I certify that any expenses for which I am requesting reimbursement from my Healthcare FSA, as itemized above, were incurred by me (and/or my
spouse and/or eligible dependents) for medical care as permitted under IRS rules and the Healthcare FSA, and have not been, and will not be,
reimbursed by any other plan.
I certify that any expenses for which I am requesting reimbursement from my Dependent Care Reimbursement Account, as itemized above, were
incurred by me (and/or my spouse) for dependent care as permitted under IRS rules and the Dependent Care Reimbursement Account, and have not
been, and will not be, reimbursed by any other plan.
I understand that expenses reimbursed through the program cannot be used to claim any federal income tax deduction or credit. To the best of my
knowledge and belief, my statements on this form are complete and true.
__________________________________________________________________________
______________
Employee Signature
Date
NOTE: Signature and supporting information are required; incomplete reimbursement forms may be delayed or returned.
Rev 6/13 - FSA-5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal