Health Care FSA - Flexible Spending Arrangement

Admin America


	DOWNLOAD: mySource Card UNREIMBURSED MEDICAL CARE EXPENSE CLAIM FORM

Instructions

You have three options for saving and/or completing the claim forms.

1) Print copies of the blank form without saving it on your computer.

2) Save the blank form to your computer for later access and close out of the web site.

3) Type your data into the online form while open on the web site and then print it before exiting the internet.

1) Print copies of the blank form without saving it on your computer.

1) Open the Unreimbursed Medical Care Expense Claim Form.

2) Click on the print icon. (You may print as many copies as you need.)

3.) Write information on the form before submission.

[ Go to the forms ]

[ Return to Instructions ]

2) Save the blank form to your computer for later access offline. (You will be able to access the form later and type information directly into the boxes from your computer without returning to the web.)

Please note that you will not be able to save a copy of the completed form on your computer. If you would like a copy of the typed form for your records, you will need to print it before closing the form on your screen.

1) Right mouse click on the link to the HRA Simple Plan Application

2) Save the form to your computer by selecting “Save as” or “Save Target as” depending on which browser version you have. (You will need to remember where the file is being saved.)

3) Open the file in Adobe Acrobat Reader

4) Complete the form by typing information into the empty boxes. (Use the Tab key to move from box to box as you type.)

5) Click on the print icon

[ Go to the forms ]

[ Return to Instructions ]

3) Type your data into the online form while open on the web site and then print it before exiting the internet.

Please note that you cannot save a completed copy of this form on your computer. If you would like a copy for your records, please print it before closing out of the form online.

1) Open the form you wish to complete from the web site

2) Complete the form online by typing in the empty boxes. (Use the Tab key to move from box to box as you type.)

3) Click on the print icon

[ Go to the forms ]

[ Return to Instructions ]

Form

Unreimbursed Medical Care Expense Claim Form

You will need to have Adobe's Acrobat Reader, Version 6.0 or greater installed on your computer to view and print the claim forms. Click on the Adobe "Get Acrobat Reader" icon to the left to obtain the free Adobe Acrobat Reader file.

Return to the Participant Claim Forms Center

Admin America, Alpharetta, GA
Phone: (770) 992-5959 or (800) 366-2961 e-mail: info@adminamerica.com