- 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.
- Dependent Care Expense Worksheet
- Extensive list of IRC section 125 eligible expenses to help you plan your Dependent Care FSA election.
- Over-The-Counter (OTC) Chart
- Sample chart of OTC items that may be eligible from your HRA or FSA. You should check your plan’s documentation to see if OTC items are eligible under your plan.
- 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.
Contact Information
245 Kenneth Drive
Rochester NY 14623-4277
Benefit Resource, LLC
PO BOX 642
Willow Grove, PA 19090
EMPLOYEES: (800) 473-9595
EMPLOYERS: (866) 996-5200
For Employees
For Employers
Company
The Beniversal and eTRAC Prepaid Mastercards are issued by The Bancorp Bank pursuant to license by Mastercard International Incorporated. Mastercard is a registered
trademark, and the circles design is a trademark of, Mastercard International Incorporated. The Beniversal and eTRAC cards are accepted at qualified merchants accepting Debit
Mastercard. The Bancorp Bank; Member FDIC.
HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.
trademark, and the circles design is a trademark of, Mastercard International Incorporated. The Beniversal and eTRAC cards are accepted at qualified merchants accepting Debit
Mastercard. The Bancorp Bank; Member FDIC.
HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.
