Forms & Documents
Please click below to access the forms you need to manage your FSA account.
- FSA Reimbursement Request Form
- FSA Direct Deposit Form
- FSA Reference Brochure
- Eligible and Ineligible Expenses
- FSA - How it works - Tax Example
Important Note: Please remember that you can fax or email any of your forms. For all reimbursement forms you submit, you must include backup documentation that follows the IRS guidelines found on the second page of the reimbursement form. Be sure that supporting documentation includes - Date of Service, Description of Service and Total Cost of Service. We must have this information before we can process the claim for payment.
Please fax completed forms to: 1.253.793.3766.
Email completed forms to: firstname.lastname@example.org
When you enroll, you will receive a packet of information that includes verification of your elections, your Summary Plan Description explaining your rights and responsibilities, reimbursement request forms with instructions on how to complete and instructions to access your account including your Access Code, Username and Password.
If you have any questions or problems, please call the benefitexpress Service Center at: 1.877.837.5017 or email us at email@example.com - Thank you.