- 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.