List of eligible medical, dental and vision expenses

List of accepted Over-The-Counter items

Flexible Spending Account administrator contact information

includes the following:

• How to file a claim

• How to change your annual election

• How to find your account balance

• How to sign up for direct deposit

Questions and Answers about filing a Healthcare
or Daycare claim

FSA Healthcare claim for reimbursement form

Daycare claim form (licensed daycare provider)

Daycare claim form (non-licensed daycare provider)

HRA claim form – please ask your Human Resource Manager for a copy of a claim form specific to your company’s HRA plan.

Travel expense claim form (used when you are enrolled in your company’s Transportation benefit plan)

Medical Travel Log Voucher (used when you want to claim mileage for medical purposes through your FSA Healthcare Account)

Change of status form (listing eligible reasons to change your election in the middle of a plan year)

Direct deposit authorization form