| Name |
Description |
|
| Standard FSA Claim Form |
This form may be used to request a reimbursement for your eligible Flexible Spending Account expenses/items. |
Download |
| Parking Form |
This form may be used to request a reimbursement for your eligible parking expenses. |
Download |
| Orthodontia Form |
This form may be used in place of an orthodontic treatment plan. You may submit this form prior to, or in conjunction with, the actual request for reimbursement. |
Download |
| HIPAA Release Form |
This form allows designated family members or other pertinent people authorization to access your account information with TaxSaver Plan. |
Download |
| True Up Claim Form |
This form may be used to request a reimbursement from your Health Flexible Spending Account if your Employer has opted for True Up. You may refer to the Useful Guides for more information about True Up or contact TaxSaver’s CSR department to confirm if your Employer’s plan is a True Up plan. |
Download |
| FSA Expense Worksheet |
This form may be used to assist you in determining potential eligible out-of-pocket FSA expenses – a great tool to use during open enrollment! |
Download |
| Debit Card Substantiation Cover Sheet |
This form may be to used to respond to a request from TaxSaver for additional documentation for a recent TaxSaver Debit Card transaction. |
Download |
| Medical Determination Form |
This form may be used to request approval for a specific treatment or dual purpose over-the-counter expenses (Physician use only). You may submit this form prior to submitting the request for reimbursement or in conjunction with the request for reimbursement. |
Download |
| Capital Expenditure Form |
This form may be used to determine the percentage use and/or value assessment of an expense. You may submit this form prior to submitting the request for reimbursement or in conjunction with the request for reimbursement. |
Download |
| Cost Differential Form |
This form may be used to determine the difference between standard average like item expense and the expense prescribed for specialized use. You may submit this form prior to submitting the request for reimbursement or in conjunction with the request for reimbursement. |
Download |
| Disabled Dependent Age 13 and Over Form |
This form may be used in conjunction with your Day Care FSA request for reimbursement. |
Download |
| COBRA Election Change Form |
This form may be used to request changes to your COBRA insurance coverage. Please note that any request to drop or change coverage should be submitted prior to the month in which you wish the change to take effect and no later than 5 days into the month. (Prepaid premiums are not refundable). |
Download |
| HSA Transfer Form (UMB) |
Use this form to transfer funds to your UMB HSA Account from another bank/trustee |
Download |
| HSA Transfer Form (WealthCare Saver) |
Use this form to transfer funds to your WCS HSA Account from another bank/trustee |
Download |
