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Other Forms

Additional forms you may need for your FSA.

Find Your Form

Select what you need from the list below. Many forms are easily submitted through your online account, while others require you to download a PDF and then submit the completed form to us.

Easy Online Account Submission

  • Direct Deposit – Sign up for direct deposit (also known as electronic funds transfer or EFT), so FSA reimbursements are deposited directly into your bank account. Just log in to your online account, go to your Profile, and click Reimbursement Method. You will then choose Direct Deposit and enter your banking information. Please note, it can take 7-10 business days to establish your Direct Deposit with your bank.
  • Authorized Individuals – You can authorize an individual to contact us on your behalf to discuss your benefits and receive or discuss your Personally Identifiable Information (PII). Just log in to your online account, go to your Profile, and click Authorized Individuals. Then enter the individual's information and click Save Changes.
  • Revoke Authorized Individuals – You can revoke an individual's authorization. Just log in to your online account, go to your Profile, and click Authorized Individuals. Then click the Revoke button by the Authorized Individual's name and follow the prompts to revoke the individual's access. Click OK to save your changes.

Download a PDF Form to Complete and Submit

  • FSAFEDS Participant Death Notification – Use this form to submit information regarding the estate of an FSAFEDS participant in order for surviving dependent(s) to submit claims. Download the Notification Form (PDF), complete the QRG , that works best for you.
  • Letter of Medical Necessity – This form provides a convenient way for your physician to provide medical necessity information for dual-purpose expenses. Download the Letter of Medical Necessity Form (PDF), complete the form, have your medical provider sign it, and then use claim submission method that works best for you.
  • Mileage Worksheet (PDF) – Use this form to log miles to and from your doctor, dentist, pharmacy or other medical care provider. When you're ready to submit a claim, sign and date the bottom of the Mileage Worksheet to certify the expense, and submit the worksheet along with your completed Health Care FSA Claim Form.
  • QRD Form for the Heart Act – Form necessary to submit a request for a Qualified Reservist Distribution (QRD). Download the HEART Act QRD Form (PDF), complete the form, and then use claim submission method that works best for you.
  • Qualifying Life Events Form (PDF) – Request enrollment or a change in your FSA election(s) due to a qualifying event as defined by the IRS. Simply download, print, complete and submit this form.