Forms & Resources

Consumer Forms (Downloadable Versions below)

FSA Claim Form - Use this form to file manual reimbursement for your Flexible Spending Account.

HRA Claim Form- Use this form to file manual reimbursement for your Health Reimbursement Arrangement.

Direct Deposit Form – Use this form to receive your reimbursements through Direct Deposit vs. Manual check.

Dependent Care "Annual" Claim form – You can complete this claim form and send it in for your Dependent Care account to make a claim inclusive of the entire plan year. A reimbursement will automatically be issued to you every time you pay into the plan if you choose this option.

Letter of Medical Necessity form– Certain items require a Letter of Medical Necessity from your physician in order to be eligible under an FSA and/or HSA plan. This is the form you would use if an item you are purchasing requires you to do so for the item to be eligible.

Debit Card Substantiation Cover Page- You can use this page as a cover page when sending in your receipts after receiving a "Receipt Request" from us due to the IRS requirement of "Debit Card Substantiation".

FSA Eligible/Ineligible List – This list is not meant to be all inclusive, but it gives you a wide variety of items that can and cannot be purchased through an FSA plan. Also check out the FSA STORE for more eligible products!

FSA-HRA-HSA Comparison Chart- View this chart to see the differences/similarities between these three types of benefits. 

Photo By : Gina Goodgion

Photo By : Gina Goodgion

Flexible Spending Account (FSA)

Health Saving Account (HSA)

Dependent Care

Mobile App