Forms Library
Below you will find a complete listing of Flexible Spending Account, Healthcare Reimbursement Arrangement and Health Savings Account forms available for download as Adobe PDFs. These documents are meant to help you learn about and manage your Flexible Spending Account or Health Reimbursement Arrangement Plan.
;
Commuter Transit
Parking
Eligible Transit Vendors List
Expenses Under the Qualified Transit and Parking Expense Plans
Parking Expense Reimbursement Form
Parking Qualified Expenses Overview (Spanish)
Parking Qualified Expenses Overview
Parking Qualified Expenses Overview No Max Amount
Transit Expense Reimbursement Form
Transit Qualified Expenses Overview (Spanish)
Transit Qualified Expenses Overview
Transit Qualified Expenses Overview No Max Amount
;
Dependent Care Flexible
Spending Accounts (DCFSA)
Calculating Annual Elections Worksheet
Recurring Reimbursement
Eligible Expenses
Reimbursement Form (Spanish)
Reimbursement Form
;
Eligible Medical
Care Expenses
Eligible Medical Care Expenses 2020 (Spanish)
Section 213d Eligible Medical Expenses
Over-the-counter Eligible Medicines
Over-the-counter FSA & HSA Employer
Over-the-counter FSA & HSA Employee

Over-the-counter FSA Only Employer

Over-the-counter FSA Only Employee

Reimbursement & Payment Options

;
Debit Card
Debit Card FAQ
;
Flexible Spending
Accounts (FSA)
Employer FAQ
Employee FAQ
Eligible Medical Care Expense
FSA and DCA Information Packet
FSA and DCA Information Packet (No Debit Card)
FSA and DCA Information Packet (Spanish)
FSA and DCA Information Packet (No Rollover)
FSA and DCA Worksheets for Calculating Annual Elections
FSA Only Information Packet
FSA Fact Sheet Myths Debunked (Grace Period)
FSA Fact Sheet Myths Debunked (Rollover)
Reimbursement Form (Spanish)
Reimbursement Form
Rollover Health Plan Update $500
Rollover Health Plan Update $550
Store Flyer
Store Flyer (Spanish)
Worksheet for Calculating Annual Elections
How to Access Your Flexible Spending Account Online
New IRS Guidelines
;
HIPAA
Authorization form FL
Authorization form MI (Spanish)
Authorization form MI
;
Health Reimbursement
Arrangements (HRA)
Employer HRA Rollover FAQ
Claim Form (Spanish)
Claim Form
Overview (No Debit Card)
Overview
;
Health Saving
Account (HSA)
How To Access HSA Online
HSA Flyer 2020
HSA Store Flyer
HSA Store Flyer (Spanish)
;
Intake
;
Letter of Necessity
Letter of Medical Necessity
;
My Benefits Account App
My Benefits Account App
My Benefits Accounts App (Spanish)
;
Member Election
Forms
Election Form – FSA/DCA/Commuter
Election Form – FSA/DCA
Election Form – LPFSA/DCA
Direct Deposit Process
Featured Success Story
Dermalogica – Customer Success Story
See how Dermalogica cut hours of tedious admin work out of open enrollment each year and continue to increase employee adoption year over year.
Recent Resources
7 Common Complex Benefits Program Examples & How to Automate Them
7 Common Complex Benefits Program Examples & How to Automate Them
Simplify Vaccine Tracking with PlanSource
Simplify Vaccine Tracking with PlanSource
What’s New in Our Titan Product Release
What’s New in Our Titan Product Release
Latest News
PlanSource Announces New Chief Executive Officer

PlanSource Announces New Chief Executive Officer