Health Savings Account (HSA) resources:

HSA Eligible Medical Expenses List

List of eligible medical, dental and vision expenses to determine what’s eligible

Flexible Spending Account (FSA) forms & resources:

FSA Healthcare claim for reimbursement form
Debit Card Claim Substantiation Form
Medical Mileage Log

Used when claiming mileage for medical purposes through your FSA Healthcare Account

FSA Eligible Medical Expenses List

List of eligible medical, dental and vision expenses to determine what’s eligible

Over-The-Counter items

List of accepted Over-The-Counter items

Change of Status form

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

Leave of Absence Form
Direct Deposit Authorization form

When offered, consult your HR department to confirm

Daycare forms:

Licensed Daycare claim form

For licensed daycare providers

Non-licensed Daycare claim form

For non-licensed daycare providers

Transit benefit forms:

Travel expense claim form

Used when you are enrolled in your company’s Transit benefit plan

Change of Status form for Transit benefit

Used when you are enrolled in the Transit benefit and need to increase or decrease your election mid-plan year

Premium Only Plan (POP) forms:

Premium Only Plan (POP) election form
POP Change of Status form

Used when you are enrolled in a Premium Only Plan and want to increase or decrease your payroll deduction for insurance premiums you are responsible for mid-plan year due to a qualifying event