Completed forms can be emailed to firstname.lastname@example.org
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
Dependent Care Account Claim Form - Complete for daycare services that occur throughout the year (daycare, preschool).
DCA Frequently Asked Questions
Letter of Medical Necessity Form -Completed by your doctor for items to be covered by you FSA or HSA funds which are normally considered ineligible.
ACH Form (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.
Online Account Instructions - If you have never set up an online account through our web portal, please use these instructions.
Enrollment Form - HRA - Enrollment forms must be submitted to your Human Resources department.
Enrollment Form - FSA- Enrollment forms must be submitted to your Human Resource department.
Enrollment Form (DCA) - Enrollment forms must be submitted to your Human Resources department.