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Below are instructions for completing and submitting your FSA claim.

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FSA Claim Instructions

1. Download claim form here.

2. Complete all information in Section 1 (please print or type). Please include your e-mail address if you want to receive an automatic e-mail notification whenever a claim is processed.

3. Attach supporting documentation. Substantiation must accompany this request form in order for claims to be considered for reimbursement. Be sure to keep copies of receipts, bills, etc. for your records. Originals will not be returned. All substantiation must include the following items to be eligible for reimbursement:

• Original date of service (not the date of payment )
• Type of service performed (refer to list of eligible expenses to identify valid services)
• Provider's name and address (and Tax ID / SSN for Dependent Care expenses)
• Amount charged to you (do not include amounts reimbursed by another source)

4. For a Healthcare FSA Reimbursement Request, complete all information in Section 2 and attach proof of expense as described above.

5. For a Dependent Care FSA Reimbursement Request, complete all information in Section 2 and attach proof of expense as described above unless providers signature is included on the claim form.

6. Sign and date Section 3.

7. Fax, mail, scan/email this form and supporting documentation directly to:

Chard Snyder
3510 Irwin Simpson Road
Mason, OH 45040
Local Phone: (513) 459-9997
Toll-free phone: (800) 982-7715
Local Fax: (513) 459-9947
Toll-free fax: (888) 245-8452
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

8. Important Reminders:

• Payments are issued after receipt and processing, subject to adjudication. Transfer
  between accounts is prohibited.
• Any items for which you are reimbursed cannot be claimed again as deductions or credits on your individual tax return at the end of the tax year.
• If a Dependent Care claim is submitted for an amount that is larger than the amount credited to your account, then payments will be issued according to the amount available.
• Anything requested above the available amount will ?backlog? and will be released as additional credits are made to your account. IRS Guidelines prohibit the advancement of Dependent Care Account funds.
• You may only be reimbursed for eligible expenses incurred during the current plan year.
• Orthodontia expenses are reimbursed as designated by the provider.
• Payment will be made to you, the participant, only. Payments cannot be made to an
  alternate payee.