The Dependent Care Reimbursement Request form is to be used when submitting a reimbursement request from your Flexible Spending Account (FSA) account for dependent care services. Please be sure to include documentation of the payment in the form of a copy of a cancelled check or paid provider statement for all expenses occurred.

Download the form (PDF).

Instructions

You may remit your Dependent Care FSA Reimbursement requests to EHIM through the mail or by fax:

EHIM
Attn: FSA Department
248-204-5604

If you have any questions about how to complete the form please feel free to contact EHIM at 800-311-3446.