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Re: Flex Spending Account enrollment and calculation
- To: noelle
- Subject: Re: Flex Spending Account enrollment and calculation
- From: http://dummy.us.eu.org/robert (Robert)
- Date: Fri, 06 Nov 2015 16:54:22 -0800
Looks like the doc wants me to see the retinologist.
> From: http://dummy.us.eu.org/robert (Robert)
> Date: Tue, 03 Nov 2015 11:43:08 -0800
>
> I realize that my ophthamologist probably will want to see me a couple of
> times. Need to account for that.
>
> I have an appt on Friday, BTW. Probably involves a dialation.
>
> > From: http://dummy.us.eu.org/robert (Robert)
> > Date: Sat, 10 Oct 2015 09:07:50 -0700
> >
> > Anything else that needs to be covered?
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Flexible Spending Account
Deduction Worksheet
This worksheet will help you calculate your applicable expenses and how
much money would be in an FSA deduction each pay period.
Medical/Dental/Vision Reimbursement Account
Annual Medical Expenses, such as:
Deductibles and co-pays $ _____________
Routine physical exams $ _____________
Prescriptions $ _____________
Chiropractic care $ _____________
Gastroenterologist $ ___________70
Podiatrist $ __________100
Other $ _____________
Annual Dental Expenses, such as:
Deductibles and co-pays $ __________170
Routine check-ups $ __________280
Orthodontia $ _____________
Other $ _____________
Annual Vision Care Expenses, such as:
Retinologist $ __________140
Ophthalmologist $ __________210
Eyeglasses $ __________300
Contact lenses, solutions, cleaners $ _____________
Other $ _____________
Slush $ __________400
Total Estimated $ _________1670
Medical/Dental/Vision Expenses
$ _____________ + _________________ = $ __________
Annual Amount # of Pay Periods* Per Pay Period
(cannot exceed
company max.)
*Weekly, 52 pay periods Biweekly, 26 pay periods Semimonthly,
24 pay periods Monthly, 12 pay periods