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Acceptable Documentation

The Right Documents Make Reimbursements Quick and Easy

All requests for reimbursement must be accompanied by the appropriate supporting documentation, as outlined below. Failure to submit acceptable documentation will lead to a delay in the reimbursement process.

Supporting Documentation for Health FSA Expenses

  • For office visits and other services: 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.
  • For prescription drugs: A pharmacy statement or receipt from your pharmacy including the patient's name, the Rx number, the name of the drug, the date the prescription was filled, and the amount.
  • For over-the-counter medicines: A written or electronic OTC prescription along with an itemized cash register receipt that includes the merchant name, name of the OTC medicine or drug, purchase date, and amount, OR a printed pharmacy statement or receipt from a pharmacy that includes the patient's name, the Rx number, the date the prescription was filled, and the amount.
  • For over-the-counter health care-related products: An itemized cash register receipt with the merchant name, name of the item/product, date, and amount.
  • For dual-purpose items or programs: A Medical Determination Form that has been completed by a doctor is required for dual-purpose items or programs that have both a medical purpose and a general health, personal, or cosmetic purpose. See specific details for each dual-purpose item or program in our eligible expenses list. The Medical Determination Form is available online through your personal CONEXIS account.

Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

For some expenses, a Medical Determination Form from a doctor may be required. See our Eligible Health FSA Expenses page. You may download a Medical Determination Form by logging in to your online account.

Supporting Documentation for Dependent Care FSA Expenses

If the employee and provider certifications on the reimbursement request form are filled out and signed, you don't need to do anything else. Simply submit the completed form.

If the provider certification is not completed and signed, you must submit an itemized statement from your dependent care provider. Just complete the reimbursement form and submit an itemized statement from the dependent care provider that includes:

  • 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.

The maximum reimbursement you may receive is equal to the current account balance in your DepCare FSA. If your reimbursement request is more than your available balance, the remaining amount will be placed in a pending status. The pended amount will be paid when additional funds are posted to your account.

Find a Request for Reimbursement Form by logging in to your online account.