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
Parking
Eligible Transit Vendors List
Expenses Under the Qualified Transit and Parking Expense Plans
Commuter Benefits General Information Flyer
Commuter Expense Reimbursement Form
Dependent Care Flexible
Spending Accounts (DCFSA)
Spending Accounts (DCFSA)
Calculating Annual Elections Worksheet
Recurring Reimbursement
Eligible Expenses
Reimbursement Form (Spanish)
Reimbursement Form
DCA FAQ
DCA General Information Flyer
Eligible Medical
Care Expenses
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)
Accounts (FSA)
Employer FAQ
Employee FAQ
FSA and DCA Information Packet
FSA and DCA Information Packet (Spanish)
FSA and DCA Worksheets for Calculating Annual Elections
FSA Flyer Grace Period
FSA Flyer Rollover
Reimbursement Form (Spanish)
Reimbursement Form
Reimbursement Account Welcome Kit
Store Flyer
Store Flyer (Spanish)
Worksheet for Calculating Annual Elections
How to Access Your Flexible Spending Account Online
How to Access Your Flexible Spending Account Online with SSN
Limited Purpose FSA with Rollover – Employee
Limited Purpose FSA with Grace Period – Employee
Limited Purpose FSA FAQ General Information
My Benefits Account App
HIPAA
Authorization form FL
Health Reimbursement
Arrangements (HRA)
Arrangements (HRA)
Employer HRA Rollover FAQ
Claim Form (Spanish)
HRA Claims Reimbursement Form (Provider Pay)
HRA Claims Reimbursement Form (Participant Reimbursement)
Overview (No Debit Card)
Overview
Health Saving
Account (HSA)
Account (HSA)
How To Access HSA Online
How To Access HSA Online with SSN
HSA Store Flyer (Spanish)
HSA Store Flyer
Intake
Letter of Necessity
Letter of Medical Necessity
My Benefits Account App
My Benefits Account App
My Benefits Accounts App (Spanish)
Member Election
Forms
Forms
Election Form – FSA/DCA/Commuter
Election Form – FSA/DCA
Election Form – LPFSA/DCA
Direct Deposit Process