FormsNote: Forms are in PDF format. You will need Adobe® Acrobat Reader to read PDF files.
- These forms are fillable. Fillable forms allow you to complete your form from the computer and print with typed input
- Card transaction substantiation
- Dependent care reimbursement request
- Healthcare flexible spending account reimbursement request
- Healthcare reimbursement arrangement account reimbursement request
- Commuter expense reimbursement request
- Premium reimbursement
If input fields are not highlighted, check "Highlight Fields" in the upper right corner; use your tab key to move from field to field.
- These forms are not fillable. Please print and complete by hand.
Enrollment and Change Requests
These forms are fillable forms. If you need a copy that you can print and complete by hand, please contact your employer.
- My employer offers a benefits card and autopay
- My employer offers a benefits card
- My employer offers autopay
- My employer does not offer a benefits card or autopay
- Additional forms for enrolling or modifying your account
If you are unsure which applies to you, please check with your employer or contact the BenefitHelp Solutions customer service team.
- Direct Deposit Form
- Letter of medical necessity
- Authorization to release protected health information
- Worksheet for Capital Expenses
To file an appeal please visit, benefithelpsolutions.com/members/fsa_file_appeal.shtml.
Send forms to:
Flexible Spending Accounts Administration
P.O. Box 67230
Portland, OR 97268-1230
888-249-5058 Fax toll-free