FSA Card Refund Request Form
Submit your refund request for an eligible FSA card purchase. Please complete all sections accurately to ensure prompt processing. This form is for authorized FSA cardholders only.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Last 4 Digits of FSA Card
*
Purchase Date
*
-
Month
-
Day
Year
Date
Purchase Amount (USD)
*
Merchant or Provider Name
*
Describe the Purchased Item or Service
*
Upload Receipt or Supporting Documentation
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Reason for Refund Request
*
Submit Request
Should be Empty: