Beneficial Links
Forms for Flexible Spending Accounts (FSA)
These PDF forms can be downloaded and printed.
 | Certification of Medical Necessity Form To use for medical services/items that require additional documentation from a licensed health care provider (submit with your completed Claim Form). | |
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| Claim Form To request reimbursement of eligible FSA expenses. (Medical FSA expenses that were paid for with a Beniversal Card cannot be submitted for reimbursement.) | |
| Dependent Care Expense Worksheet Extensive list of IRC 125 eligible expenses to help you plan your Dependent Care FSA election. | |
| Dependent Care Receipt For your dependent care provider to use as a receipt for eligible dependent care services provided to you (submit with your completed Claim Form). | |
| Direct Deposit Authorization Form To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information. | |
| Enrollment Form To enroll in your FSA Plan. | |
| Medical Expense Worksheet Extensive list of IRC 125 eligible expenses to help you plan your Medical FSA election. | |
| Mileage Expense Certification Form To provide supporting documentation when claiming mileage for eligible services from your Medical FSA (submit with your completed Claim Form). | |
| Participation Waiver Form To decline participation in the tax-free benefit. | |