The following PDF forms contain fill-able fields and automatic calculations, but must be printed and mailed or faxed after completion.

Note to Participants: Use only the forms that correspond to your employer’s plan as designated in the Summary Plan Description (SPD).

• Flex Card Receipt Submission Form 
• Use this form for submission of documentation to substantiate Flex Card transactions
• FSA Medical and Dependent Care Combination Claim Form 
• Standard form for medical and dependent care claim submissions
• FSA Medical Only Claim Form 
• Standard form for only medical claim submissions
• Health Reimbursement Arrangement (HRA) Claim Form 
• Standard form to be used to submit medical expenses incurred by the participant and eligible dependents
• Individual Premium Reimbursement Claim Form 
• Claim form to be used for reimbursement of insurance premium payments
• Letter of Medical Necessity
  • Form to assist you and your healthcare provider in providing the information we need in order to process your claim.
• Orthodontic Claim Form 
• Schedules orthodontic treatments for automatic processing and reimbursement without subsequent re-submission of the same claim
• Transportation Reimbursement Claim Form
• Standard form to be used for reimbursement of transportation and/or parking benefits