Forms

Qualifying Expenses

  • Qualifying Medical Care Expenses
  • Specific Expenses
  • Over-the-Counter Medication Expenses
  • Non-Qualifying Medical Care Expenses
  • Qualifying Dependent Care Expenses
  • Alphabetic listing of Typically Denied Expenses

    • Cafeteria Plan Forms

  • Dependent Care Claim Form
  • Medical Care Claim Form
  • Insurance Premium Reimbursement Claim Form
  • Participant Savings Estimate
  • Change in Status Form
  • Authorization For Disclosure Of An Individual's Health Information
  • Request For Alternative Confidential Communication
  • Allowable Providers for the Benny Card
  • Services and Expenses Eligible For Reimbursement Under the FSAFEDS Program
  • Cafeteria Plan Participant Direct Deposit Authorization Form

    • Expense Worksheets

  • Medical Care Expense Worksheet
  • Dependent Care Expense Worksheet