Forms

Forms

TO SUBMIT A REQUEST FOR FLEX PLAN REIMBURSEMENT:

Submit a signed and dated claim form along with substantiation of the expense. Substantiation must show:

  • Actual Dates of Service
  • Service Provider’s Name
  • Family Member Receiving Service
  • Type of Service Performed
  • Dollar Amount for Which You are Responsible After Insurance Has Paid
  • Signature of the Day Care Provider (if claiming daycare)

COPIES OF CHECKS, CHARGE CARD RECEIPTS, BANK ACCOUNT STATEMENTS, PERSONAL COMPUTER PRINTOUTS, CASH REGISTER RECEIPTS (except OTC meds), PAID ON ACCOUNT RECEIPTS ARE NOT ALLOWED BY THE IRS AS SUBSTANTIATION

All of the below listed forms are in PDF format. Please download the file(s) needed and either print or save.

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Flexible Spending Account (FSA) Plan Reimbursement Claim Form

Unreimbursed Medical\Vision\Dental Claim Form
Dependent Care Claim Form

Health Reimbursement Arrangement (HRA) Claim Form

HRA Reimbursement Claim Form

Health Savings Account (HSA)

HSA Enrollment Form

HSA Custodial Agreement

Change In Status

Change in Status Form

Enrollment Form

Enrollment Form

Debit Card Request Form

CCFlex Benny Debit Card Order Form

(Must be sponsored by your Employer)