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: flex@chard-snyder.com
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.
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