Spending Account Forms

FSA

• Additional Health Spending Card Request Form
• Certificate of Medical Necessity
• Claim Terms and Conditions
• Claims Exchange Election Form
• Debit Card Transaction Dispute Form
• Dependent Care Account - Reimbursement Request
• Enrollment Form
• FSA/HRA Data Change Form
• QMCSO - Reimbursement Request
• Reimbursement Account HIPAA Authorization
• Reimbursement Account HIPAA Authorization Cancellation
• Reimbursement Request Form

HRA

• Additional Health Spending Card Request Form
• Certificate of Medical Necessity
• Claim Terms and Conditions
• Claims Exchange Election Form
• Debit Card Transaction Dispute Form
• FSA/HRA Data Change Form
• QMCSO - Reimbursement Request
• Reimbursement Account HIPAA Authorization
• Reimbursement Account HIPAA Authorization Cancellation
• Reimbursement Request Form

HSA

• Additional Debit Card Request Form
• Beneficiary Change Spousal Consent Form
• Contribution Form
• Death Distribution Request Form
• Debit Card Transaction Dispute Form
• Distribution Request Form
• Enrollment Form
• Informational Authorization Form
• Informational Change Notification
• Power of Attorney Form
• Power of Attorney Disability Incapacity
• Transfer Form
• Welcome Letter

QTB

• Additional Health Spending Card Request Form
• Claim Terms and Conditions
• Debit Card Transaction Dispute Form
• Parking and Transit Enrollment Form
• Reimbursement Request Form
• Reimbursement Account HIPAA Authorization
• Reimbursement Account HIPAA Authorization Cancellation

ICHRA

• Certificate of Medical Necessity
• Dependent Care Account - Reimbursement Request
• Reimbursement Account HIPAA Authorization
• Reimbursement Account HIPAA Authorization Cancellation
• Reimbursement Request Form with Individual Coverage HRA

LSA

• Lifestyle Spending Account Reimbursement Request Form