FSA Claim Form and
Debit Card Substantiation Request Form

Submit this form to substantiate a debit card transaction, or to claim FSA reimbursement for an out-of-pocket expense.

Section 1: Employee Information
The following information must be included:
     • Employee Name
     • Employee Address
     • Employee Social Security Number
     • Employee Phone Number
     • Employee Email Address

Section 2: Claim Information
The following information must be included:
     • Debit Card Used For Transaction?
     • Date of Service
     • Patient Name
     • Relationship
     • Name of Provider
     • Description of Service
     • Amount of the Claim

Cancelled checks, non-detailed credit card receipts, or generic cash receipts do not provide all the information necessary to substantiate claims and cannot be accepted as receipts. Statements with “Previous Balance," “Balance Forward," or “Paid on Account” also do not contain all of the necessary information and cannot be accepted.

Instructions

1.  All sections of the claim form must be completed, including signature and date.
2.  Submit your claim using one of four available methods:
     • For fastest reimbursement, use the Summit portal or the Summit mobile app.  Click here for instructions.
     • Email the completed, signed form and all receipts to abb@datapathadmin.com
     • Fax the completed, signed form and all receipts to 501-687-3282
     • Mail the completed, signed form and all receipts to DataPath Administrative Services, Inc., 1601 Westpark Dr Ste 6, Little Rock, AR 72204


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