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.

Guides & Worksheets:

FSA Rollover Health Plan Update

FSA Rollover Health Plan Update

FSA Information Packet: Debit Card

FSA Information Packet: Debit Card

FSA Information Packet: Non-debit card

FSA Information Packet: Non-debit card

FSA Store Coupon

FSA Store Coupon

How to Access Your Flexible Spending Account Online

How to Access Your Flexible Spending Account Online

Managing your Flexible Spending Plan and Benefits MasterCard

Managing your Flexible Spending Plan and Benefits MasterCard

Using the My Benefits Accounts App

Using the My Benefits Accounts App

Health Care Reform and FSA Changes to Over-the-counter Eligibility for Reimbursement

Health Care Reform and FSA Changes to Over-the-counter Eligibility for Reimbursement

Tax Savings Illustration for Health or Dependent Care Flexible Benefits Plans

Tax Savings Illustration for Health or Dependent Care Flexible Benefits Plans

Worksheet for Dependent Care Annual Elections

Worksheet for Dependent Care Annual Elections

Worksheet for Health Care Annual Elections

Worksheet for Health Care Annual Elections

Eligible Medical Care Expenses

Eligible Medical Care Expenses

Qualified Parking Expense Plan Overview

Qualified Parking Expense Plan Overview

Qualified Transit Expense Plan Overview

Qualified Transit Expense Plan Overview

Eligible and Ineligible Expenses under the Qualified Transit and Parking Expense Plans

Eligible and Ineligible Expenses under the Qualified Transit and Parking Expense Plans

Forms:

Healthcare Flexible Spending Account Reimbursement Form

Healthcare Flexible Spending Account Reimbursement Form

Dependent Care Flexible Spending Account Reimbursement Form

Dependent Care Flexible Spending Account Reimbursement Form

Health Reimbursement Arrangement (HRA) Reimbursement Form

Health Reimbursement Arrangement (HRA) Reimbursement Form

Direct Deposit Form

Direct Deposit Form

Qualified Transit Expense Reimbursement Form

Qualified Transit Expense Reimbursement Form

Qualified Parking Expense Reimbursement Form

Qualified Parking Expense Reimbursement Form

HIPAA Authorization Form

HIPAA Authorization Form

Letter of Medical Necessity

Letter of Medical Necessity

Guides and Worksheets in Spanish

Cuenta de Gastos Flexibles (FSA Enrollment Kit with Debit Card)

Cuenta de Gastos Flexibles (FSA Enrollment Kit with Debit Card)

Cuenta de Gastos Flexibles (FSA Enrollment Kit without Debit Card)

Cuenta de Gastos Flexibles (FSA Enrollment Kit without Debit Card)

Gastos Elegibles del FSA para el Cuidado Médico 2019 (Eligible Medical Care Expenses 2019)

Gastos Elegibles del FSA para el Cuidado Médico 2019 (Eligible Medical Care Expenses 2019)

La Aplicación de Mi Cuenta de Beneficios (My Benefits Accounts App)

La Aplicación de Mi Cuenta de Beneficios (My Benefits Accounts App)

Un Repaso del Plan de Gastos Calificados del Estacionamiento (Qualified Parking Expense Plan)

Un Repaso del Plan de Gastos Calificados del Estacionamiento (Qualified Parking Expense Plan)

Un Repaso del Plan de Gastos Calificados del Transporte (Qualified Transit Expense Plan)

Un Repaso del Plan de Gastos Calificados del Transporte (Qualified Transit Expense Plan)

¿No sabe en qué usar el dinero de su FSA? (FSA_Store_Flyer)

¿No sabe en qué usar el dinero de su FSA? (FSA_Store_Flyer)

¿No sabe en qué usar el dinero de su HSA? (FSA_Store_Flyer)

¿No sabe en qué usar el dinero de su HSA? (HSA_Store_Flyer)

Forms in Spanish:

PlanSource-Healthcare-FSA-Reimbursement-Form-Spanish

Cuidado del Dependiente FSA Formulario De Reembolso (Dependent Care FSA Reimbursement Form)

PlanSource-Health-Reimbursement-Claim-Form-Spanish

Formulario de Reembolso para Gastos Médicos (HRA Reimbursement Form)

PlanSource-Direct-Deposit-Form-Spanish

Formulario de la Autorización del Depósito Directo (Direct Deposit Form)

PlanSource-Dep-Care-FSA-Reimb-Form-Spanish

Cuidado del Dependiente FSA Formulario De Reembolso (Dependent Care FSA Reimbursement Form)

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