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Forms for Flexible Spending Account (FSA) Plan / Health Reimbursement Account (HRA) Plan

These PDF forms can be downloaded and printed.

FSA / HRA Forms

Use for either an FSA or HRA Plan.

• Certification of Medical Necessity
  For services/items that require additional documentation from a licensed health care provider (submit with your completed Claim Form).

 

• Claim Form
  To request reimbursment of eligible expenses that were not purchased with a Beniversal® Card.

 

• Direct Deposit Reimbursement Authorization
  To authorize reimbursements to be deposited directly into your bank account.
  
  

• Mileage Expense Certification Log
  To provide supporting documentation when claiming mileage for eligible medical services (submit with your completed Claim Form).
  

FSA Forms

Use only for an FSA Plan.

• FSA Change Form
  To report changes in status, address, elections, etc. for your FSA Plan.

 

• FSA Change Form with Beniversal
  To report changes in status, address, elections, etc. for your FSA Plan that offers the Beniversal Card.

 

• FSA Dependent Care Expense Worksheet
  Extensive list of IRC 125 eligible expenses to help you plan your dependent care FSA election.

 

• FSA Dependent Care Receipt
  For your dependent care provider to use as a receipt for services provided to you.

 

• FSA Enrollment Form
  To enroll in your FSA Plan.

 

• FSA Enrollment Form with Beniversal
  To enroll in your FSA Plan that offers the Beniversal Card.

 

• FSA Medical Expense Worksheet
  Extensive list of IRC 125 eligible expenses to help you plan your medical FSA election.

 

• Participation Waiver Form
  To decline participation in the tax-free benefit.
  

HRA Forms

Use only for an HRA Plan.

• HRA Enrollment / Change Form
  To enroll and/or report changes in your HRA Plan.

 

• HRA Enrollment / Change Form with Beniversal
  To enroll and/or report changes in your HRA Plan with Beniversal Card.

 

• HRA Medical Expense Worksheet
  Extensive list of expenses that may be eligible under your HRA Plan.