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Aetna Explanation of Benefits

Sample Aetna Explanation of Benefits highlighted for expenses and …

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Cigna Explanation of Benefits

Sample Cigna Explanation of Benefits highlighted for expenses and …

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Debit Card Claim Substantiation Form (FOR FSA ONLY)

Use this form to submit substantiation for a debit card claim for your FSA.

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Direct Deposit Authorization Form

Use this form to authorize direct deposit of your claim reimbursements. Consult your HR department to confirm if this option is available to you.

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Eligible Expenses – Code 213(d)

This table details the expenses eligible for reimbursement in an HSA or FSA plan.

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Eligible Over-The-Counter Items

This table details over-the-counter items eligible for reimbursement in an HSA or FSA plan.

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FSA Change of Status Form

Use this form when you want to change your Health FSA election mid-plan year

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FSA Claim Reimbursement Form

Use this form to file a reimbursement claims for your FSA.

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Health Net Explanation of Benefits

Sample Health Net Explanation of Benefits highlighted for expenses and …

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HRA Coinsurance Claim Form

Use this form to file a reimbursement claim from your HRA for coinsurance …

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HRA Deductible Claim Form

Use this form to file a claim for reimbursable HRA expenses relating to …

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IRS Contribution Limits

IRS contribution limits for HSA, HRA, FSA, Transportation plans. Includes Highly Compensated and medical mileage limits. Shows index by …

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Kaiser Explanation of Benefits

Sample Kaiser Permanente Explanation of Benefits highlighted for expenses and …

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Leave of Absence Form

Use this form to inform SBA of an impending Leave of Absence.

, , all fsa status
Licensed Dependent Care Claim Form

Use this form to submit a claim for FSA dependent care reimbursement from a licensed provider.

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Medical Mileage Log

Use this form to track your mileage for plan reimbursement purposes.

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Non-licensed Dependent Care Claim Form

Use this form to submit a dependent care FSA claim for a non-licensed provider.

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POP Change of Status Form

Use this form when you want to increase or decrease your POP payroll deduction for insurance premiums mid-plan year due to a qualifying event.

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POP Election Form

Use this form to update your POP …

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Premera Explanation of Benefits

Sample Premera Explanation of Benefits highlighted for expenses and …

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Premium Only Plan (POP) Election Form

Use this form to enroll in your company’s Premium Only Plan.

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Regence Explanation of Benefits

Sample Regence Explanation of Benefits highlighted for expenses and …

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Summit Claim Form

Use this for to file a claim for reimbursement for your FSA, HRA or Transportation plan.

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Transit Plan Change of Status Form

Use this form to change your status mid-year if you are enrolled in a Transit Benefit Plan.

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Transportation Claim for Reimbursement Form

Use this form to submit a claim for reimbursement from a Transit Benefit Plan.

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United Healthcare Explanation of Benefits

Sample United Healthcare Explanation of Benefits highlighted for expenses and …

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