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Forms for Flexible Spending Accounts (FSA)

These PDF forms can be downloaded and printed.

 

Certification of Medical Necessity
For services/items that require additional documentation from a licensed health care provider (submit with your completed Claim Form).
 
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.
 
Claim Form
To request reimbursement of eligible expenses that were not purchased with a 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.
 
Direct Deposit Reimbursement Authorization
To authorize reimbursements to be deposited directly into your bank account.
 
FSA Enrollment Form
To enroll in your FSA Plan.
Do not use this form if your employer offers BRI website enrollment. Click HERE for online enrollment.

FSA Enrollment Form with Beniversal
To enroll in your FSA Plan that offers the Beniversal Card.
Do not use this form if your employer offers BRI website enrollment. Click HERE for online enrollment.

FSA Medical Expense Worksheet
Extensive list of IRC 125 eligible expenses to help you plan your medical FSA election.
 
Mileage Expense Certification Log
To provide supporting documentation when claiming mileage for eligible services (submit with your completed Claim Form).
 
Participation Waiver Form
To decline participation in the tax-free benefit.

  

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