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FORM
1100: Compensation Redirection Agreement
Use this form to participate in your company's FSA
plan. (If reporting a change in status, Form
1101 must accompany this form.)
FORM
1101: Health and Dependent Care Change Request Form
(8½”x14”)
Use this form to make a change in your flexible
spending account (FSA) election or to change your address.
FORM
1102: Dependent Care Spending Reimbursement Request Form
Use this form to request reimbursement from
the Dependent Care spending account of your FSA.
FORM
1103: Dependent Care Receipt for Services Form
A caregiver or provider of service can use
this form as a receipt for dependent care services provided.
FORM
1104: Mileage Reimbursement Request Form
Use this form to claim, under
your FSA, mileage used to obtain qualified medical services for a physical
disease, defect or illness.
FORM
1105: Debit
Card Substantiation Form
Use this form to substantiate purchases made with
your MedBen Visa Debit Card.
FORM
1106: Substantiation of Manual Claims
This form lists the supporting documents that must
accompany requests for reimbursement.
FORM
1107: Health Care Spending Reimbursement Request Form
Use this form to request reimbursement from
your Health FSA account.
FORM
1109: Orthodontia Services Reimbursement Request Form
An orthodontist (or authorized bookkeeper) can use this form to
request reimbursement for services.
FORM
1114: Request for Debit Card
Use this form to receive a
debit card for your dependent or replace a lost or stolen card.
Notice of Appeal/Designation of
Authorization Form
Employees wishing to file an formal appeal of a
disputed claim should use this form. They can also
designate another entity to file an appeal on their behalf.
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