I am requesting reimbursement for medical expenses for myself that I paid for out of pocket.
The Medical Care Reimbursement Account allows you to request reimbursement for eligible health items & service for yourself, your spouse and any tax dependents.
I am requesting reimbursement for medical expenses for my spouse and/or children that I paid for out of pocket.
Complete all personal information and the medical care reimbursement section of the Medical Care / Dependent Care Reimbursement Request Form
I am requesting reimbursement for transportation / parking expenses to my doctor.
Complete all personal information and the medical care reimbursement section of the Medical Care / Dependent Care Reimbursement Request Form
I am requesting reimbursement for daycare expenses for my children.
Complete all personal information and the dependent care reimbursement section of the Medical Care / Dependent Care Reimbursement Request Form
My daycare provider does not provide me with a receipt for payment.
Complete the Sample Dependent Care Receipt and have your provider sign to authorize. Submit this completed receipt along with a Reimbursement Request Form
I am sending my receipt to Igoe for a purchase that I made with my Flex card.
Complete the Flex Benefits Card Receipt Coversheet
I need my spouse to work with Igoe to resolve an issue on my account.
Complete the Health Information Release Form and submit to Igoe. Indicate the specific topic in which Igoe is authorized to speak with the individual named on your form to ensure that your account is updated correctly.
I need my secretary to work with Igoe regarding my recent request for reimbursement.
Complete the Health Information Release Form and submit to Igoe. Indicate the specific topic in which Igoe is authorized to speak with the individual named on your form to ensure that your account is updated correctly.
I need to request reimbursement for orthodontia for one of my dependents. How do I make sure that I am reimbursed properly?
Have your provider complete the Ortho Treatment Statement and submit this completed form along with your completed Medical Care/ Dependent Care Reimbursement Request form to Igoe.
I have an item / service that is typically not considered eligible for reimbursement, but my doctor is telling me that I must have it. How do I determine if this is eligible under my plan for reimbursement?
Have your provider complete the Letter of Medical Necessity and submit this completed form along with your completed Medical Care/ Dependent Care Reimbursement Request form to Igoe.
I am requesting reimbursement for my vanpool expenses.
Complete the Transit & Parking Request Form.
I am requesting reimbursement for transportation costs to and from my employer.
Complete the Transit & Parking Request Form.
I am requesting reimbursement for my office parking expenses.
Complete the Transit & Parking Request Form.
Form Descriptions
Medical Care/Dependent Care Reimbursement Form (Interactive)
Medical Care / Dependent Care Reimbursement Request Form – This Interactive form allows you to request reimbursement for either your medical care reimbursement account, dependent care (daycare) reimbursement account or both (if applicable). Complete this form on your computer then print, sign, scan & upload the form using our secure online utility under your personal login.
Flex Health Information Release Form
Due to HIPAA requirements, this form is required each time you would like to have another individual contact IAS on your behalf. Complete this form if you wish to give permission for someone other than yourself to be given information about your FSA account. IAS will not discuss your account with anyone other than you unless this form is provided.
Sample Dependent Care Receipt
Complete this form to meet the requirements for documenting your day care expenses. This form, once completed, may act as your receipt for expenses incurred.
Letter of Medical Necessity
This form was designed to provide a template for your physician to authenticate the eligibility of your expense. Please note that for expenses to be eligible under the medical FSA, they must be deemed medically necessary. If you are in doubt about the eligibility of your expense, ask your provider to complete this form as a precaution.
Transit & Parking Request Form (Interactive)
Transit/Parking expenses are only reimbursable if your employer offers a Transit/Parking Reimbursement Plan. This form may be used if you are requesting reimbursement from your employer-sponsored Transportation and/or Parking plan. Please use the medical care / dependent care request form if you wish to request reimbursement for transportation related to a medical expense.
Flex Benefits Card Receipt Coversheet
The Benefits Card Cover Sheet is intended for the use of Benefits MasterCard holders only. This form is ONLY for items and services that you paid for using your Flex Benefits MasterCard and is only required if you have received an email indicating that additional documentation is needed to determine the eligibility of your expense.
Ortho Treatment Statement
This form may be completed by your provider to act as notification of the orthodontic treatment duration and cost. All items requested on this form are required for reimbursement. Either a copy of this completed form or a copy of your orthodontia contract indicating all items requested on this form must be submitted with your request for reimbursement to determine eligibility & payment.