Flexible Benefit Forms

To request reimbursement for eligible expenses, complete the claim form for your plan below. Follow the instructions outlined on the form.

• FSA Claim Form (PDF)
• HRA Claim Form (PDF)

If you would like claims reimbursements to be directly deposited into your checking or savings account, complete the Direct Deposit Authorization Form below. Instructions on how to submit your authorization are included on the form.

• Authorization for Direct Deposit Form (PDF)

Some expenses must be medically necessary in order to be eligible for reimbursement. Along with your claim, you must submit a Medical Determination Form completed by your health care provider. To learn if your expense requires this form, see eligible expenses.

• Medical Determination Form (PDF)

To request replacement of your access card, or order an additional card, complete the form below. Follow the instructions outlined on the form.

• Replacement Card Form (PDF)