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  • FSA and HRA Forms and Materials

    The documents on this page are in PDF format. If you do not have Adobe Acrobat Reader on your computer, click here to download the free software.

  • FSA and HRA Forms

  • Icon Authorization to Disclose PHI
    Icon Carryover Provision Amendment
    Icon Debit Card Receipt Submission Form
    Icon Debit Card Refund Submission Form
    Icon Dependent Care Recurring Expense Form
    Icon Direct Deposit Setup - Request for Reimbursement from FSA or HRA
    Icon EasyPay Enrollment Form
    Icon Employee FSA Change Form
    Icon FSA Enrollment Form
    Icon FSA Enrollment Form (en Espanol)
    Icon FSA Expense Allocation Worksheet
    Icon Health Reimbursement Arrangement Opt-out Form
    Icon HRA Enrollment and Change Form
    Icon Letter of Medical Necessity
    Icon Medical mileage reimbursement worksheet
    Icon Request For Reimbursement - FSA and HRA
    Icon Request for Reimbursement - FSA or HRA (en Espanol)
    Icon Request For Reimbursement - Transportation and Parking

  • FSA and HRA Information

  • Icon EasyPay Flier
    Icon Examples of Eligible Expenses - Dependent Care FSA
    Icon Examples of Eligible Expenses - General Purpose FSA
    Icon Examples of Eligible Expenses - Limited Purpose FSA
    Icon Examples of Eligible Expenses - Limited Scope FSA
    Icon FSA Participant Guide
    Icon FSA/HRA: Online Account Access for Participants
    Icon Grace Period FAQ
    Icon Healthcare Reform FAQ: Over-the-counter Medications
    Icon Manley Services is Now PacificSource Administrators
    Icon Obstetric and Prenatal Care Guidelines
    Icon Ortho Guidelines
    Icon Prepaid Benefits Card Flier
    Icon PSA: A Mobile App to Manage Your Reimbursement Accounts
  • If you have any trouble printing these forms, please e-mail the webmaster. Please include your name and company name and indicate whether you are a participant or employer.