FSA Medical Care Recurring Expense Form

Claim Form Section A: Declaration of Services

• Enter the start and end date of the services provided
• Complete the provider’s charges (you will need to include the receipt)

Claim Form Section B: Employee/Participant Information

Enter the following information:

• Employer Name
• Employee/Participant Name
  • Address
  • Social Security Number
  • Phone
  • Email

Claim Form Section C: Provider Information

Enter the following information:

• Name of Service Provider
  • Address
  • Account/Claim Number (if applicable)
• Name of Person Receiving the Service

Claim Form Section D: Certification and Signature

Read the paragraphs, sign and date.

FSA_Medical_Recurring_Expense_Form