Flexible Spending Account Forms

Health Care FSA Forms
Letter of Medical Necessity: This example shows the items that need to be on a Letter of Medical Necessity from your provider

Reimbursement Claim Appeal Form: If you think that your claim for reimbursement was denied in error, use this form to appeal the denied claim and provide details about why you feel your claim should be approved. Please submit this form within 180 days from the day the claim was originally submitted.

Claim Form: The easiest ways to file a claim are either online or via the mobile app. If you need a paper claim form, please call the Participant Service Center for assistance.

Mileage Reimbursement Claim Form: To be reimbursed for eligible mileage or parking expenses, please document the required information on this worksheet and submit it with your claim.

Qualified Reservist Distribution (QRD) Form: Reservists called to active duty may be eligible to receive a taxable distribution of unused funds from their Health Flexible Spending Arrangement (Health FSA). To determine your eligibility for a QRD, please complete and submit this form.

Dependent Care FSA Forms
Dependent Care Certification Form: Use this form to have your dependent care provider certify the care provided in lieu of a detailed receipt.