Flexible Spending Account Forms

Claim Forms

Use these forms to submit a claim:

• Medical Expense Reimbursement Account Claim Form
• Dependent Care Expense Reimbursement Account Claim Form
• Letter of Medical Necessity
• In order to determine eligibility for Potentially Eligible Expenses, you will need to obtain a Letter of Medical Necessity from your healthcare provider.
• Member Requested Authorization for Release of Information (ARI)
• Complete this form if you want SelectAccount to release information about you to someone else (for example: an agent or family member).
• Appeal Form
• Use this to provide additional information to have a denied claim reviewed.

Election Forms

Complete these forms to sign up for optional features of your reimbursement account:

• Direct Deposit Form
• Authorize electronic transfer of your reimbursements from your FSA to your bank account. Note: this form can also be completed online.
• Medical Crossover Form
• Have your medical claims automatically submitted from your health plan to your account administrator. Note: this form can also be completed online.
• Dental Crossover Form
• Have your dental claims automatically submitted from your dental plan to your account administrator. Note: this form can also be completed online.

Brochures and Information Sheets:

• Flexible Spending Account Plan Employee Brochure
• Learn about Flexible Spending Accounts and how they can benefit you.
• Premium Conversion Only Plan Employee Brochure
• See the benefits of a Premium-only Flexible Spending Account.
• Over-the-Counter Drugs Reimbursement Guidelines
• Find out which over-the-counter drugs are eligible for reimbursement from your SelectAccount.
• FSA Eligible/Ineligible Medical Expense Listing

Planning Worksheets

Use these worksheets to help estimate your eligible expenses for the coming year:

• Plan Year Election Worksheet
• Dependent Care Tax Savings Worksheet
• Orthodontia Worksheet