Tip for Administrator-specific

Always keep itemized receipts — credit card statements alone are not sufficient for FSA/HSA reimbursement

Tip for Administrator-specific

The Explanation of Benefits (EOB) from your insurer is the gold standard for documentation

Tip for Administrator-specific

Over-the-counter medications and menstrual care products are eligible FSA/HSA expenses (since the CARES Act)

Tax-Related Healtheasy

FSA / HSA Reimbursement Claim

Administrator-specific · FSA/HSA administrator

Request for reimbursement of qualified medical expenses from FSA or HSA. Requires documentation of expenses (receipts, EOBs).

Form Details

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Where to Submit This Form

🌐

Submit claims through your FSA/HSA administrator's website or app

Most administrators (WageWorks, HealthEquity, Optum Bank, etc.) offer online claim submission and mobile apps.

📬

Mail claim form and receipts to your FSA/HSA administrator

Use the claim form provided by your administrator.

📠

Fax claim form and receipts to your FSA/HSA administrator

Fax number is on the administrator's website or the claim form.

Filing Deadline

Healthcare FSA: claims must be submitted by the plan's run-out deadline (typically 90 days after the plan year ends). HSA: no deadline — funds never expire.

Required Attachments

📎 Completed claim/reimbursement form
📎 Itemized receipt or Explanation of Benefits (EOB) showing: date of service, description of service, provider name, and amount
📎 Proof that the expense was not covered by insurance (if applicable)

Processing Time

Online/app submissions: 1-5 business days. Mail/fax: 1-2 weeks. Direct deposit reimbursement is fastest.

What Happens Next

The administrator will review the claim and reimburse you via direct deposit or check. If documentation is insufficient, they will request additional information. Keep copies of all receipts.

Tips for This Form

✓ Always keep itemized receipts — credit card statements alone are not sufficient for FSA/HSA reimbursement
✓ The Explanation of Benefits (EOB) from your insurer is the gold standard for documentation
✓ Over-the-counter medications and menstrual care products are eligible FSA/HSA expenses (since the CARES Act)
✓ HSA tip: you can pay out of pocket now, save receipts, and reimburse yourself from the HSA years later — letting the HSA grow tax-free

More Tax-Related Health Forms

Premium Tax Credit (PTC)

Form 8962 · Internal Revenue Service

Reconciles advance premium tax credit (APTC) payments with actual PTC eligibility based on final income. Required if you or a family member received APTC through the Marketplace. Failure to file blocks future APTC.

Health Insurance Marketplace Statement

Form 1095-A · Health Insurance Marketplace

Shows months of Marketplace coverage, premiums, and APTC paid. Sent to enrollees by mid-February. Used to complete Form 8962.

Health Coverage (1095-B)

Form 1095-B · Health insurance companies / Medicaid agencies

Shows who was covered and which months. Sent by insurers and Medicaid agencies. Not filed with tax return but should be kept as a record of coverage.

Employer-Provided Health Insurance Offer and Coverage

Form 1095-C · Large employers (50+ FTE)

Reports health coverage offered by employer. Sent to employees by March 2. May be used to determine PTC eligibility.

Health Savings Accounts (HSA)

Form 8889 · Internal Revenue Service

Reports HSA contributions and distributions. Must be filed if you had any HSA activity during the year. Part 1 covers contributions (potential tax deduction).

FSA Enrollment Form

Employer-specific · Employer / FSA administrator

Election to participate in a Flexible Spending Account during open enrollment. Specifies annual pre-tax contribution amount. Use-it-or-lose-it rules apply (with possible carryover or grace period).

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the FSA/HSA administrator or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.