Flex and HSA Forms

Flexible Spending Account (FSA)

• Reimbursement Request
• Administrative Services Agreement
• Letter of Medical Necessity for Flexible Spending Account
• Enrollment Application Flexible Spending Account
• Employer Setup Checklist for Flexible Spending Account

Health Savings Account (HSA)

• HSA Transfer Form
• HSA Employer Group Enrollment Application

Other Forms

• Premium Only Plan (POP) Employer Setup Request
• IRC Section 125 - Cafeteria Plan Change in Status/Termination Election