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Other Forms

Additional forms you may need for your FSA.

Find Your Form

Select what you need from the list below. Many forms are easily submitted through your online account, while others require you to download a PDF and then submit the completed form to us.

Easy Online Account Submission

  • Direct Deposit – Sign up for direct deposit (also known as electronic funds transfer or EFT), so FSA reimbursements are deposited directly into your bank account. Just log in to your online account and click Direct Deposit. Then follow the step-by-step instructions.
  • FSAFEDS Consent – Authorize use or disclosure of your personal information regarding your Dependent Care FSA. Just log in to your online account and click FSAFEDS Consent. Then follow the step-by-step instructions.
  • HIPAA Authorization – Authorize use or disclosure of your individually identifiable health information to specific persons or entities. Just log in to your online account and click HIPAA Authorization. Then follow the step-by-step instructions.
  • HIPAA Revoke Authorization – Revoke an authorization or restrict the use or disclosure of your individually identifiable health information. Just log in to your online account and click HIPAA Revoke Authorization. Then follow the step-by-step instructions.

Download a PDF Form to Complete and Submit

  • Letter of Medical Necessity – This form provides a convenient way for your physician to provide medical necessity information for dual-purpose expenses. Download the Letter of Medical Necessity Form (PDF), complete the form, have your medical provider sign it, and then use claim submission method that works best for you.
  • FSAFEDS Participant Death Notification – Use this form to submit information regarding the estate of an FSAFEDS participant in order for surviving dependent(s) to submit claims. Download the Notification Form (PDF), complete the QRG , that works best for you.
  • QRD Form for the Heart Act – Form necessary to submit a request for a Qualified Reservist Distribution (QRD). Download the HEART Act QRD Form (PDF), complete the form, and then use claim submission method that works best for you.
  • Qualifying Life Events Form (PDF) – Request enrollment or a change in your FSA election(s) due to a qualifying event as defined by the IRS. Simply download, print, complete and submit this form.