Medical FSA Expense Worksheet

Benefit Resource and BRI are tradenames of Benefit Resource, LLC. Benefit Resource, LLC is an affiliate of Inspira Financial Health, Inc. and Inspira Financial Trust, LLC. Benefit Resource, LLC does not provide legal, tax or financial advice. Please contact a professional for advice on eligibility, tax treatment and other restrictions. Inspira and Inspira Financial are trademarks of Inspira Financial Trust, LLC.

The Beniversal and eTRAC Prepaid Mastercards are issued by The Bancorp Bank, N.A., Member FDIC, pursuant to a license by Mastercard International Incorporated and may be used for eligible expenses everywhere Mastercard is accepted. Mastercard and the circles design are registered trademarks of Mastercard International Incorporated.

HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.