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Flexible Benefit Forms

Claim Forms

To request reimbursement for eligible expenses, complete the claim form for your plan below. Follow the instructions outlined on the form.

Direct Deposit Form

If you would like claims reimbursements to be directly deposited into your checking or savings account, complete the Direct Deposit Authorization Form below. Instructions on how to submit your authorization are included on the form.

Medical Determination Form

Some expenses must be medically necessary in order to be eligible for reimbursement. Along with your claim, you must submit a Medical Determination Form completed by your health care provider. To learn if your expense requires this form, see eligible expenses.

Benefit Access Debit Card Replacement Form

To request replacement of your access card, or order an additional card, complete the form below. Follow the instructions outlined on the form.

Benefit Access Mobile App

Get fast, easy and secure access to your FSA, HSA, HRA, and TSA accounts.

Insurance products and services offered through McGriff Insurance Services, LLC, a subsidiary of TIH Insurance Holdings, LLC, are not a deposit, not FDIC insured, not guaranteed by a bank, not insured by any federal government agency and may go down in value.

McGriff Insurance Services, LLC. CA License #0C64544