Skip Navigation LinksHome > My Spending Accounts > Get Forms > What Form Should I Use  Sign On
 
 
Resources
Questions?
Call 800-633-8818 Option 1
Hours: M – F, 8am – 5pm PT
Did you know you can text us?
What Forms Should I Use?
  • I am requesting reimbursement for medical expenses for myself that I paid for out of pocket.
  • I am requesting reimbursement for medical expenses for my spouse and/or children that I paid for out of pocket.
  • I am requesting reimbursement for transportation / parking expenses to my doctor.
  • I am requesting reimbursement for daycare expenses for my children.
  • My daycare provider does not provide me with a receipt for payment.
  • I am sending my receipt to Igoe for a purchase that I made with my benefit card.
  • I need my spouse to work with Igoe to resolve an issue on my account.
  • I need my secretary to work with Igoe regarding my recent request for reimbursement.
  • I need to request reimbursement for orthodontia for one of my dependents. How do I make sure that I am reimbursed properly?
  • 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?
  • I am requesting reimbursement for my vanpool expenses.
  • I am requesting reimbursement for transportation costs to and from my employer.
  • I am requesting reimbursement for my office parking expenses.


Form Descriptions


FSA Reimbursement Request Form (Interactive)
FSA Reimbursement Request Form – This Interactive form allows you to request reimbursement for either your medical care spending account, dependent care (daycare) spending 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.



Dependent Care Reimbursement Request and Provider Receipt (Interactive)
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.


Commuter Plan Reimbursement (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.


Bicycle Plan Reimbursement
Bicycle related expenses are only reimbursable through and (change to an) employer sponsored Bicycle Reimbursement Plan. To be eligible for reimbursement from this plan you must be enrolled, and you must use your bicycle and (change to as) your primary means of transportation to and from work. Additionally, funds claimed from this account are only reimbursable if funds have not already been claimed from a transit or parking plan account within the for (remove the for) the same benefit month.


HRA Reimbursement Request Form (Interactive)
HRA Reimbursement Request Form – This form allows you to request reimbursement for eligible health items, outlined in your employer's plan documents.



Premium Reimbursement (Interactive)
Hospital and Other Insurance Premiums are only reimbursable if your Employer offers a Hospital and Other Insurance Premium Conversion Plan. This interactive form allows you to request reimbursement for either your hospital or other insurance premium conversion account. Complete this form on your computer, print, sign, scan & upload the form using our secure online utility under your personal login.


Flexible Benefits Card Substantiation Coversheet (Interactive)
The Benefit 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.


Medical Necessity Template (Interactive)
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. The IRS requires a prescription that meets state requirements if your physician has recommended an over-the-counter (OTC) medicine or drug if you wish to seek reimbursement from your medical care spending account. Use of this form does not satisfy state prescription requirements. If you are in doubt about the eligibility of your expense, ask your provider to complete this form as a precaution.


Orthodontia Treatment Statement (Interactive)
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.


Limited Purpose FSA Conversion Form (Interactive)
Use this form to submit an Explanation of Benefits (EOB) showing that the deductible for your HDHP has been met. This is not a reimbursement request form and will not result in claim remittance.


HIPAA Release Form (Interactive)
Due to HIPAA requirements, this form is required each time you would like to have another individual or organization access PHI related to your Flexible Benefit Plan Account or your COBRA continuation.