Forms & Documents

Claim Form

To request reimbursement of eligible expenses.

PHI Authorization/Revocation Form

Medical FSA Expense Worksheet

Extensive list of IRC section 125 eligible expenses to help you plan your Medical FSA election.

Opt Out Form FSA

To decline participation in the tax-free benefit.

Enrollment/Change Form FSA

To enroll in your FSA Plan or to report changes in status, address, elections, etc.

Dependent Care Receipt

For your dependent care provider to use as a receipt for eligible dependent care services provided to you. The document can be found here.

Dependent Care Expense Worksheet

Extensive list of IRC section 125 eligible expenses to help you plan your Dependent Care FSA election.

Mileage Expense Certification Form

To provide supporting documentation when claiming mileage for eligible services from your pre-tax account.

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.

Certification of Medical Necessity Form

To use for medical services/items that require additional documentation from a licensed health care provider.