For dependent care expenses and medical costs that you paid for out-of-pocket, CDPHP provides you convenient ways to submit claims.

Submit Your FSA Claim Online

  • Log into the secure member site
  • Under Online Forms, click FSA Claim Form
  • Select Dependent Care Claim or Health Care Claim
  • Complete the form and upload your receipts

Submit Your FSA Claim by Mail

  • Download and print the FSA Claim Form
  • Complete the form. All fields are required.
  • Attach copies of your receipts and/or copies of supporting documentation indicating:
    • Name of provider
    • Date of service or date product was purchased
    • Type of service or product (drug name is required for prescription claims)
    • Your out-of-pocket expense for the service or product (amount not otherwise reimbursed)
    • Name of employee or dependent for whom the service or product was provided
    • Amount you paid for service or product
  • Mail to: CDPHP Health Funding, P.O. Box 6130, Albany, NY 12206-3960.

Copies of statements, bills, and receipts are sufficient when providing supporting documentation.