Beneficial Links
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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). |
| Change Forms To report changes in status, address, elections, etc. for your FSA Plan. | |
| Use if your Plan does not feature the Beniversal Card. |
| Use if your plan year began on or before March 1, 2010 and features the Beniversal Card. |
| Use if your plan year began on or after April 1, 2010 (or does not feature the Beniversal Card). |
| Claim Form To request reimbursement of eligible expenses that were not purchased with a Beniversal Card. |
| 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 services provided to you. |
| Direct Deposit Reimbursement Authorization To authorize reimbursements to be deposited directly into your bank account. |
| Enrollment Forms To enroll in your FSA Plan. Do not use these forms if your employer offers BRI website enrollment. | |
| Use if your Plan does not feature the Beniversal Card. |
| Use if your plan year began on or before March 1, 2010 and features the Beniversal Card. |
| Use if your plan year began on or after April 1, 2010 (or does not feature the Beniversal Card). |
| 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. |