Dependent Care Flexible Spending Account Claim Form:

Use this to form if you have a Dependent Care Flexible Savings Account to submit a claim for reimbursement for dependent care expenses. Instructions for submission appear at the end of the form.

Commuter Claim Form:

Use this form to submit a claim for costs incurred for parking or public transportation. Instructions for submission appear at the end of the form.

Healthcare Spending Form:

Use this form to list itemized bills, receipts, or insurance carrier’s explanation of benefits for reimbursement.  Instructions for submission appear at the end of the form.

Limited Purpose Health Care Flexible Spending Account Claim Forms:

Use this form if you have a Limited Purpose Health Care Flexible Spending Account to submit a claim for reimbursement for health care expenses. Instructions for submission appear at the end of the form.

Flexible Spending Account Claim Form- Medical Necessities:

Use this Flexible Spending Account form for any medical necessities. Instructions for submission appear at the end of the form.

Orthodontia Claim Form:

Use this form for unreimbursed orthodontia expenses. Instructions for submission appear at the end of the form.

Orthodontia Guide:

An informational guide on the Orthodontia process as it relates to your Flexible Spending Account reimbursement.

Itemized Receipt Guide:

An informational guide on what is required to substantiate your Flexible Spending Account expenses using itemized receipts.