Houston ISD FSA · administered by Zynera
Samples · for reference
What good FSA supporting documents look like
Real examples of the statements, receipts, and Explanation of Benefits that substantiate a health FSA claim — by category. Every one here is a fictitious, watermarked sample; use them to see exactly what to send.
Five things a good document shows
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Date of service — when care happened.
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Description of service — what it was, with codes.
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Amount you paid — your out-of-pocket.
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Provider name — who provided it.
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Patient name — who received care.
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Proof of payment — paid, not an estimate.
Medical
Doctor visits, labs, specialists
Itemized Statement
Dermatology — new patient + biopsy
West Houston Dermatology Associates
Dental
Cleanings, restorative, periodontal
Vision
Exams, glasses, contacts
Pharmacy
Prescription receipts & histories
Dependent Care (DCFSA)
Different rules: provider Tax ID/SSN · dependent name · dates of care already provided · amount
Dependent-Care Statement
Child daycare — monthly statement
Little Sprouts Learning Center
Annual & Multi-Visit Statements
Full-year itemized statements & patient-portal examples
Explanation of Benefits
The gold standard — substantiates on its own
