Provided below are several forms you may use with your VEBA or flexible spending account. If you need any assistance with these forms, please call our Flex Hotline at (800) 284-8412. An associate will be glad to assist you.
This form is used for requesting reimbursement from your Flexible Spending Account.
This form is used for requesting mileage reimbursement from your Flexible Spending Account.
This form is used to request reimbursement from your Health Reimbursement Account.
This form is a list of both covered and non-covered over the counter items for your Flexible Spending Account.
This form is used to request debit cards for dependents on your Flexible Spending Account.
Use this form to verify a claim that has already been reimbursed by the use of your debit card. This document can be edited on screen for your convenience.
This form is a list of eligible merchants for use of your debit card.
This is a list of merchants that have registered as meeting the IRS 90% Rule that at least 90% of gross sales are from prescriptions/Rx or qualified over-the-counter healthcare products. This list will be continually updated as additional merchants are registered. Check back often!
This form gives basic instructions on how to use your FSA benefits card for eligible purchases.
This form is used for requesting reimbursement from your VEBA account.
This form is a partial list of eligible expenses for your Flexible Spending Account.