Manual Claim Form – To be completed when submitting for reimbursement or direct to provider payment. Must be accompanied by a detailed statement and/or explanation of benefits when applicable. Completed forms can be emailed to email@example.com
** You can now enter your claims and upload your documentation through your ONLINE PORTAL.
DCA Continual Reimbursement – Complete for daycare services that occur throughout the year (daycare, preschool). Not to be used for summer camps. Completed forms cam be emailed to firstname.lastname@example.org.
Direct Deposit – Complete to have claims directly deposited into your checking or savings account. Once completed we will save your information so there is no need to send in this form each time. Completed forms can be emailed to email@example.com.
Online Account Instructions – New Users – If you have never set up an online account please use these instructions.
Enrollment Form – HRA – Enrollment forms must be submitted to your Human Resources department.
Enrollment Form – FSA, DCA – Enrollment forms must be submitted to your Human Resource department.