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Dependent Care Reimbursement

Download the Form

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

Attn: FSA Department

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