Flexible Spending Account
Claim Reimbursement Instructions
1. Complete all information on the front page (please print/type).
2. Attach supporting documentation. A copy of a receipt or EOB must accompany this request for each claim
submitted for reimbursement. Do not highlight any part of your receipt. Be sure to keep your original receipts,
bills, etc., for your records. All receipts are destroyed daily. Each claim request must include the following
information to be eligible for reimbursement:
Original date of service (not the date of payment)
Description of service performed (refer to list of eligible expenses to identify valid services)
Provider’s name and address (if submitting receipts for dependent care expenses)
Amount charged to you (do not include amounts reimbursed or paid by another source)
3. Health care or limited purpose FSA reimbursement request: Complete all required information and
attach proof of expense as described above. Note: Cancelled checks are NOT acceptable as proof of
payment. Limited purpose FSAs may only reimburse claims for dental and/or vision expenses.
4. Dependent care FSA reimbursement request: Complete all required information and attach proof of
expense as described above. Note: Cancelled checks are acceptable as proof of payment.
5. You MUST sign and date the CLAIM CERTIFICATION section on the front of this page.
6. Fax or mail this form and supporting documentation directly to Chard Snyder:
Fax: 888.245.8452 (Please DO NOT include a fax cover page.)
Mail: 3510 Irwin Simpson Road, Mason, OH 45040
7. If you have questions please contact us:
Call Customer Service: 855.824.9284
Visit our website: PeopleFirst.MyFlorida.com
Email your questions: FloridaAskPenny@chard-snyder.com For security reasons, please do not
send claims or personal information
through email.
8. Important reminders:
All requests are saved as electronic images. To ensure your claim is processed as soon as possible and
to avoid delays, keep the following in mind:
Do NOT use a fax cover page when faxing.
Do NOT highlight any part of your receipts, bills, etc.
Only send copies of receipts, bills, etc. (Keep your originals.)
Multiple receipts should be totaled on one claim form.
Payments are issued after receipt and processing, subject to claim approval.
Claims may not be paid across accounts (health care from dependent care and vice versa).
Dependent care claims may only be reimbursed for the amount you have in your account at the time
of your claim. If your claim is for more than the balance in your account, the rest of your claim will be
paid when the balance is sufficient to cover the claim.
Other considerations:
Any items for which you are reimbursed cannot be claimed again as deductions or credits on your
individual tax return at the end of the tax year.
You may only be reimbursed for eligible expenses incurred during the current plan year and grace
period. Note: Orthodontia expenses may be reimbursed over a period of time if a copy of the patient’s
contract is submitted.
Payment will be made directly to you. Payments cannot be made to a provider or another person
unless you submit claims online.
