Claim Forms
Use these forms to submit a claim:

Medical Expense Reimbursement Account Claim Form
You can now fill out this form online before you print. When entering information into the form, use Tab to move between the fields. To complete your claim submission after printing the completed form, sign, attach supporting documentation and submit to SelectAccount.

Dependent Care Expense Reimbursement Account Claim Form
Use this form to request funds from your dependent care FSA.  Have your provider complete Section C to ensure the fastest possible processing of your claim request.

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 health care provider.

Appeal Form
Use this to provide additional information to have a denied claim reviewed.

Reimbursement Return Form
Use this form to return a payment to your account.

Election Forms

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

Direct Deposit Form
Sign in to authorize electronic transfer of your reimbursements from your FSA to your bank account.

Medical Crossover Form
For members with an account that includes the crossover feature, sign in to view or update your crossover election.

Dental Crossover Form
For members with an account that includes the crossover feature, sign in to view or update your crossover election.

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 a family member).

Link to Forms on the Blue Cross and Blue Shield of Kansas Website (www.bcbsks.com)

Please note that clicking on this link will direct you away from the SelectAccount website.

Planning Worksheets

Orthodontia Worksheet

Brochures and Information Sheets

Flexible Spending Account Quick Start Guide
Learn about flexible spending accounts and how they can benefit you.

Premium Only Plan Employee Brochure
See the benefits of a Premium Only plan.

Orthodontic Tip Sheet
See some simple steps to help you get your orthodontia claims processed faster and your money sooner.

Over-the-Counter Drugs Eligible Expense Listing
Find out which over-the-counter drugs are eligible for reimbursement from your spending account.

FSA Eligible Medical Expense Listing

FSA Calculator
Estimate potential tax savings when using an FSA to pay for eligible expenses.