Wex dependent care reimbursement. 2) A section for the participant to certify that the provided information is accurate and that the Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. This is different from a medical FSA because you cannot use all of the funds Day 1. Mar 11, 2026 · Our Recurring Dependent Care program. If mailing, be sure to use the WEX mailing address: PO Box 2926, Fargo, ND 58108-2926. This allows employees to set aside pre-tax dollars from their paycheck to pay for eligible child or adult day care expenses. It includes: 1) Instructions for the dependent care provider to complete the form by providing the dependent's name, date range of services, amount charged, provider name, and signature. Documentation must be retained for your records and provided to WEX when requested to do so (if a receipt is unavailable, a signature from the provider is sufficient). If any information on this request form changes You pay your dependent care expenses as usual, then submit claim forms and receipts to WEX, the company that administers the FSA for UC. What to Know The Dependent Care Flexible Spending Account (FSA) allows you to put aside pretax dollars to use toward eligible care expenses for your dependents. All rights reserved. It is administered by WEX Discovery Benefits. Because your Dependent Care FSA contributions reduce your taxable income, participation will lower your taxes. Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. Spend your DepCare FSA dollars. For recurring costs, submit our Recurring Dependent Care Form. This card may only be used at eligible merchant locations: health care providers, pharmacies and general merchandise stores that can auto-approve eligible items at the register. After each payroll contribution has been made, those funds are applied to your account and available for reimbursement. This is diferent from a medical FSA because you cannot use all of the funds Day 1. Powered by WEX Health FLEXIBLE SPENDING ACCOUNT REIMBURSEMENT REQUEST FORM Please Complete When Faxing Outsource your benefits accounts and COBRA Increase employee engagement and retention by offering simplified benefit accounts that support your employees’ well-being. Submit the completed form to Wex Health as your supporting documentation for the claim. Sep 1, 2020 · Save strategically Submit all of your dependent care expenses at the end of the plan year for one lump sum reimbursement to give yourself a hard-earned “bonus”. Your receipt(s) accompanying this form should include the following information: (1) Date of service, (2) Description of service or item purchased, (3) Dollar amount (patient responsibility only) and (4) Name of provider. The Dependent Care FSA is designed to help you pay for the cost of child and/or adult care so that you – or if you’re married, you and your spouse – can work. What is the maximum amount I can elect for the Dependent Care FSA? The IRS maximum allowed contribution amount is $5,000 annually. However, we also accept documentation from the provider if it includes dates of service, description of service, dollar amount and provider name. Reimbursement for eligible health care expenses is easy with the WEX Benefits Card. Dependent Care Verification Form Please note that this form does not replace the need to submit a dependent care claim. If submitting expenses for my Dependent Care Account, I have obtained or made reasonable eforts to obtain the provider’s Tax ID (TIN) and I will include the TIN on IRS Form 2441, which I must attach to my • Dependent Care Account (Dependent Care FSA): Allows reimbursement of dependent care expenses incurred by eligible dependents. Employees may enroll in both Medical and Dependent Care FSA plans. Documentation must be retained for your records and provided to Mercer Marketplace when requested to do so (if a receipt is unavailable, a signature from the provider is suficient). A Flexible Spending Account (FSA) lets you set aside pre-tax money from your paycheck to reimburse yourself for many common health care and dependent care expenses. Jul 19, 2023 · This form is to be completed by your provider after dependent care expenses have been incurred and should be used in place of dependent care documentation. The dependent care FSA lets you pay for eligible dependent care expenses while you reap the benefits of additional tax savings. You can claim expenses for: any child under age 13 who you can claim as your dependent for federal income tax purposes your spouse who is physically or mentally unable to care for himself or herself and who lives with you for more This form is to be completed by your provider after dependent care expenses have been incurred and should be used in place of dependent care documentation. Please enable Javascript to access this website. If your cost of dependent care per month exceeds your monthly payroll deductions, you can fill out a Recurring Nov 2, 2021 · Dependent Care Verification Form Please note that this form does not replace the need to submit a dependent care claim. Documentation must be retained for your records and provided to WEX Health, Inc. If any information on this request form changes Health FSA — for qualifying medical expenses for you and your eligible family members Dependent Care FSA — for eligible daycare or caregiving expenses for your child (up to age 13) or eligible adult dependent Each pay period Mercy will contribute towards your Dependent Care FSA. If your cost of dependent care per month exceeds your monthly payroll deductions, you can fill out a Recurring Dependent Care Request Form at the See how WEX dependent eligibility verification services provide employers with a convenient, optimized solution to stay compliant and save money. 3 KB Name: Discovery Benefits Guide to Filing Claims Type:pdf Size:264 KB Name: Out-of-Pocket Claim Type:pdf Size:102 KB Name: Dependent Care FSA This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. If any information on this request form changes Care FSA - up to $5,000 per year tax-free care Flexible Spending Account (FSA) can save potentially hundreds of dollars per year This program is administered by WEX. We offer the following flexible spending accounts, administered by WEX: Health Care Flexible Spending Account (FSA) Dependent care FSA The dependent care FSA allows you to use the funds in your account as you contribute to the dependent care FSA from your paycheck. If any information on this request Provide quality central services necessary for the operation of state government at the most economical price. You can contribute up to $7,500 per family to the Dependent Care FSA for the 2026 calendar year. Attach this form to an online or debit card claim via your online account or to an Out-of-Pocket Reimbursement Request Form. It allows you to use pre-tax dollars to pay for eligible dependent care FSA expenses, such as day care, preschool, or after-school care for a qualified individual. With the DCRA, you put aside money from your pay on a pre-tax basis to cover anticipated dependent daycare expenses while you work or attend school. Pro tip For recurring costs, submit our Recurring Dependent Care Form! It makes claim filing simple because you only need to submit one form once in order to get reimbursed each pay Aug 24, 2021 · Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. Powered by WEX Health I understand that WEX, including its agents and employees, will not be held liable if I submit ineligible expenses for reimbursement. A person with eligible dependents sets up the account with their employers, allowing money to be withheld from their salary to go into the account and outside of the WEX will send you a reimbursement for the amount of the claim, or for the amount remaining in your Dependent Care FSA, if less. If submitting expenses for my Dependent Care Account, I have obtained or made reasonable efforts to obtain the provider’s Tax ID (TIN) and Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. Note: You can only be reimbursed for the money you put into the account. This way, eligible childcare and other dependent care costs are a little less. Learn more about the HRA benefit here. We walk through what the claims process looks like. If your cost of dependent care per month exceeds your monthly payroll deductions, you can fill out a Recurring Dependent Care Request Form at the This document is a Dependent Care Verification Form that can be used to substantiate dependent care claims. Jan 6, 2016 · SECTION 125 – DEPENDENT CARE Document Your dependent care flexible spending account is a reimbursement account offered by your employer as part of your benefits package. Fees associated with kindergarten, as well as tuition for children in first grade and above are not eligible for reimbursement under a Dependent Care FSA. Help your team members save on out-of-pocket qualified medical, dental, and vision expenses, or qualified dependent care expenses with intelligent, seamless, and user-friendly flexible spending accounts (FSAs) from WEX. If any information on this request form changes Flexible Spending Accounts (FSAs) help you save money by allowing you to deduct tax-free dollars from your pay to cover certain health and dependent care expenses you incur during the year. Claims Reimbursement You may fax, mail or submit your dependent care claim to the carrier for reimbursement online. If any information on this request form changes After filing your dependent care reimbursement claim online, complete this Dependent Care Verification form and have your daycare provider sign where indicated. Search our helpful, interactive eligible expense list to determine HSA, FSA, HRA, or commuter benefits eligible expenses. Health Savings and Spending Accounts, including Health Savings Accounts, Flexible Spending Accounts, Commuter Benefits, Health Reimbursement Arrangements, and COBRA Administration ofered by Voya Benefits Company, LLC (in New York, doing business as Voya BC, LLC). Attach this form to an online or debit card claim via your online account or to a Claim Form. All you need is just a tap, click, call, or swipe away. To qualify, you and your spouse (if applicable) must be employed full-time or your spouse must be a full-time student. For example: if you have contributed $200 into your Dependent Care FSA, but your after-school care was $300 for the month, you can only be reimbursed for $200. Documentation must be retained for your records and provided to WEX when requested to do so (if a receipt is unavailable, a signature from the provider is suficient). If any information on this request Shop for FSA-eligible products and learn about eligible expenses with the most comprehensive eligibility list at FSA Store. WEX benefits login Enrolled in a WEX health benefit account or using WEX for benefits administration? Select your account type to find your login page. WEX will send you a reimbursement for the amount of the claim, or for the amount remaining in your Dependent Care FSA, if less. Dependent care flexible spending account (DepCare FSA) Administered by WEX Health You set aside money for your dependent care flexible spending account (DepCare FSA) from your paycheck before taxes are taken out and use the funds for caregiving expenses for your child (up to age 13) or eligible adult dependent. WEX will send you a reimbursement for the amount of the claim, or for the amount remaining in your DepCare FSA, if less. Jun 7, 2022 · An FSA claims process that leads to fast reimbursement matters to participants. Dependent Care Assistance Plan (DCAP) (better known as a dependent care flexible spending account (DPFSA)) is a type of flexible savings account (FSA) that can be used by individuals with dependents to reduce taxable income. You’re spending the money either way. Chard Snyder is a third party administrator (TPA) of employee benefits plans. If any information on this request form changes Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. Also they cannot contribute over the $7,500 Dependent Care maximum combined between both plans. . This form is used when you seek reimbursement for any eligible out-of-pocket expenses that have occurred. when requested to do so (if a receipt is unavailable, a signature from the provider is sufficient). Rather, it is intended to accompany your dependent care claim and serve as a substitute for the documentation required to substantiate that claim. Healthcare expenses for an eligible dependent would be reimbursed using a Health Care FSA, NOT a Dependent Care FSA. The IRS offers a tax credit to those who have childcare or dependent care expenses. Interested in saving for child or elder care expenses? Check out the dependent care FSA Need assistance with your benefits account? Contact customer support and get your questions answered without delay for your benefits administration needs. Only Jul 11, 2022 · Dependent Care Flexible Spending Account (FSA) Welcome to your dependent care flexible spending account (FSA), brought to you by Minnesota Healthcare Consortium (MHC) and administered by WEX Health, Inc. 7 KB Name: Recurring Dependent Care Request Form Type:pdf Size:96. If your cost of dependent care per month exceeds your monthly payroll deductions, you can fill out a Recurring Dependent Care Request Form at the {{metaDescription}} Javascript is not enabled. If you’re paying for daycare expenses with your account and enroll in this program, you only need to submit one reimbursement form per year for each daycare provider used. They do need to be cognizant that they cannot double dip, meaning submit for reimbursement for the same expense under both plans. The dependent care FSA allows you to use the funds in your account as you contribute to the dependent care FSA from your paycheck. (WEX). See plan documents for details. WEX is the global commerce platform for fuel and fleet, employee benefits, and business payments. The information below is a summary. Enrolling in a dependent care FSA plan saves you money. 2004-2026. This means when payroll isprocessed and your paycheck is available to you, your dependent care FSA contributionswill be applied to your account and available for reimbursement. Provide quality central services necessary for the operation of state government at the most economical price. If submitting expenses for my Dependent Care Account, I have obtained or made reasonable eforts to obtain the provider’s Tax ID (TIN) and The DepCare FSA for Academic Student Employees allows you to pay for eligible expenses for care of your child or eligible adult dependent on a pretax basis. No. If any information on this request form changes I understand that WEX, including its agents and employees, will not be held liable if I submit ineligible expenses for reimbursement. If submitting expenses for my Dependent Care Account, I have obtained or made reasonable efforts to obtain the provider’s Tax ID (TIN) and I will include the TIN on IRS Form 2441, which Administered by: WEX Health You set aside money for your health flexible spending account (FSA) from your paycheck before taxes are taken out and use the funds for eligible health care expenses for you and your eligible family members. Expenses related to before and after school care or nursery school expenses qualify if the care is primarily custodial. You need to submit all claims by April 15 of the following year. Simplify your business and let WEX handle the complex. Offered at no charge to you. We would like to show you a description here but the site won’t allow us. Founded in 1988, we provide customized benefit solutions that meet the needs of organizations nationwide for flexible spending accounts, health reimbursement arrangements, health savings accounts, smart commuter, COBRA, and other pre-tax benefits. Step 2b: Dependent Care Reimbursement Information — Having your dependent care provider sign this form is the preferred method to file for reimbursement. Learn how adding an HRA from WEX to your benefits offering can help you provide employees with a tax-advantaged way to save for out-of-pocket expenses. © WEX Health Inc. Dependent Care Reimbursement Accounts Carnegie Mellon offers a Dependent Care Reimbursement Account (DCRA) to help you lower your dependent care expenses by paying with tax-free money. You can login to your WEX Portal to see your co-worker contribution and Mercy’s contribution. Flexible Spending Accounts Dependent Care - Flexible Spending Account (FSA) - All Benefit Groups Employees can enroll in a Dependent Care Flexible Spending Account (FSA). Flexible Spending Accounts WEX Flexible Spending Accounts, administered by WEX, offer a smart way to stretch your dollars by setting aside pre-tax funds to pay for eligible healthcare and dependent care expenses. Dec 18, 2025 · SECTION 125 – DEPENDENT CARE Document Your dependent care flexible spending account is a reimbursement account offered by your employer as part of your benefits package. Transaction Dispute Form COBRA Social Security Disability Extension SSDE Form Recurring Dependent Care Request Form Out of Pocket Reimbursement Request Form (Spanish) Out of Pocket Reimbursement Request Form COBRA Open Enrollment Change Form Medical Necessity Form (Spanish) May 2, 2025 · A flexible spending account (FSA) allows participants to save money by setting aside pre-tax dollars to pay for eligible medical, dental, vision and dependent care expenses incurred by you, your spouse, or your eligible dependents. Central services include maintenance of the Capitol Complex buildings and grounds, maintenance of state-owned buildings under the purview of the bureau, procurement, engineering, risk management, records management, fleet and travel, central mail, central duplicating, state and Funds available as you contribute Fundswillbe available to you as they’re deducted from your paycheckand contributed to the plan. Central services include maintenance of the Capitol Complex buildings and grounds, maintenance of state-owned buildings under the purview of the bureau, procurement, engineering, risk management, records management, fleet and travel, central mail, central duplicating, state and We would like to show you a description here but the site won’t allow us. Each plan year (July 1 – June 30), you must elect the annual amount you want to contribute to each account. WEX directly administers a variety of reimbursement and savings accounts, plus other solutions, including: Your Trust Health Reimbursement Arrangement (HRA) & Over-the-Counter (OTC) Benefits Submit completed HRA claim forms to WEX by mail, email, or online. Jan 7, 2021 · Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. It is administered by WEX Benefits. It makes claim filing simple because you only need to submit one form once in order to get reimbursed each pay period. If any information on this request form changes Keep it easy by choosing a Dependent Care FSA from Voya Financial. Have questions about the OTC benefit? Learn more about the OTC Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. Essentially, you pay yourself back with tax-free money for expenses you’d have anyway, such as child care. Only Recurring Dependent Care Request Form This form is to be completed each plan year and as changes occur when you want to receive recurring reimbursement of dependent care expenses. If submitting expenses for my Dependent Care Account, I have obtained or made reasonable eforts to obtain the provider’s Tax ID (TIN) and I will include the TIN on IRS Form 2441, which I must attach to my federal income tax return. This form is to be completed by your provider after dependent care expenses have been incurred and should be used in place of dependent care documentation. I understand that WEX, including its agents and employees, will not be held liable if I submit ineligible expenses for reimbursement. STAFF WEX Dependent Care FSA Name Type Size Name: Discovery Benefits Out-of-Pocket Reimbursement Request Form Type:pdf Size:57. ilmqbfrl wtpz hypn tityk ymeh guir azyk teb eobylg pssnf