Quick Forms

Flexible Spending Account

FSA_DCAP_HRA_Claim Form

Dependent Care Overview

Claim Rules and Filing Instructions *

Authorization for Direct Deposit

Day Care Provider Receipt

HIPAA Release of Information

Letter of Medical Necessity _ 2018

* Medical Expense Sample Worksheet

According to the IRS Website "You must keep records as long as they may be needed for the administration of any provision of the Internal Revenue Code. Generally, this means you must keep your records that support your deduction (or an item of income) for 3 years from the date you file the income tax return on which the deduction is claimed." For more information on tax filing, please check with your accounting professional.

Guidelines & Information

• Over the Counter (OTC) Guide

• FSA Eligible Expenses (sample list) 

• 125Company Benefit Card FAQs

• FSA Non-Eligible Expense Examples

• Quick Guide for Reimbursement

• Flexible Spending Account. Is it Right for You?

• Determine your Pre-Tax Election & Pay Check Savings Overview

• 2014 - IRS Released Contribution Limits for HSA -- May, 2013
• 2015 - IRS Released Contribution Limits for HSA -- June, 2014

HSA Consumer Notice Regarding Electronic Delivery of Tax Forms 2017

New Educational Tools and Resources

• Flexible Spending Accounts Calculator

• Want to See if a Specific Product is Still Fully Covered?

• Health Care Pricing Guide

• Dependent Care Overview 2018

• Dependent Care vs. Dependent Tax Credit Guide - Tax info 2016

• IRS Publication 503 _ Child and Dependent Care Expenses 2017

Quick Link: "Desktop Claim Request Receipt Upload"  

Transportation Account

         "Transportation Changes for 2018"

• Transportation Claim Form -

• Transportation Claim Rules and Filing Instructions

• What is eligible and what is not!

* Your Summary Plan Description (SPD) will describe your specific eligible claim types. If you have any specific questions, please contact your HR department or 125Company.

All forms are also available in your personal account login portal.

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