FSA Medical Care Recurring Expense Form

How to submit a claim for for recurring medical expenses. **All sections of the claim form must be completed in order to receive reimbursement, including signature and date.**

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.

For fastest processing, fax to (501) 687-3282 or email to benefits@datapathadmin.com