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Dependent Care Documentation Form PampA Group
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People also ask
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What documentation is required for FSA reimbursement?
The service documentation will need to include: • Provider Name • Service Dates (not payment date) • Patient Name • Type of Service • Out- of-Pocket Cost or Your provider may sign the form confirming the date of services, charges and other service or product information in lieu of providing separate documentation or ...
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What receipt is needed for a dependent care FSA?
The Claim Form must be completed entirely, dated and signed. Receipts must state the provider name, provider contact information, the dependent name, service dates (begin and end), a description of the service and the expense amount. A credit card receipt or canceled check is not adequate documentation.
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Can dependent care FSA be used for babysitters?
Yes, your dependent care FSA can reimburse you for expenses paid to a babysitter under the age of 19 as long as the babysitter is not you or your spouse's child, stepchild, foster child, or tax dependent.
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What documentation do I need for dependent care FSA?
Provider of service documentation that includes: Provider OR Name, Service Dates (not payment date), Dependent Name, Type of Service and Out-of-Pocket Costs • Your provider may sign the form confirming the date of services, charges and other service in lieu of providing separate documentation.
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What documents must be completed to receive FSA?
To apply for FSA, you should submit a completed DD Form 1561, Statement to Substantiate Payment of Family Separation Allowance (FSA), to your servicing personnel office.
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What is acceptable documentation for FSA reimbursement?
For office visits: Your health plan's Explanation of Benefits (EOB) statement or an itemized receipt or bill from the provider that includes the patient's name, a description of the service, the original date of service and your portion of the charge.
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What needs to be on receipt for FSA reimbursement?
Start and end dates of service • Dependent's name and date of birth • Itemization of charges • Provider's name, address, and tax ID or Social Security number • Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.
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Does IRS require receipts for FSA?
IRS rules require that all FSA and HRA claims be substantiated. If the claim cannot be auto-substantiated, the employee is required to submit documentation to support the claim. You should save itemized receipts and documentation for all health care services—even when you paid using your payment card.
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