Flexible Spending Account Document Archives | BRI

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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.