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Forms for Participants

Below are printable forms (in PDF format) for FSA and HRA participants.

Form NameForm DescriptionCan I Do This Online?
Claim Form Submit a reimbursement claim along with your documentation
Dependent Care Receipt Form Give this form to your dependent care provider to complete if you are not provided with a receipt, then submit with Claim Form  
Enrollment Guide & Plan Participation Form Complete with your administrator to enroll in Flexible Spending Accounts  
Employee Carry Over Information Learn more about the new Carry Over feature for FSAs  
Direct Deposit Authorization Complete and submit to have your reimbursements deposited directly into your checking or savings account (if offered by your plan)
Flex Card Information and Request Form Request a new or replacement Flex Card to pay for eligible expenses (if offered by your plan)  
Letter of Medical Necessity Have your medical provider complete this form for reimbursement of dual-purpose items  
Orthodontia Reimbursement Learn about the newly revised FSA rules for orthodontia reimbursement  
Prenatal Care/Delivery: Memo and Provider Letter Learn about FSA rules for Prenatal Care and Delivery  
Medical Mileage Worksheets: 20172018, 2019 Use these worksheets to determine your Medical Mileage reimbursement  
HSA Guide How to get started with your new HSA