Flexible Benefits
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Use these documents and forms to learn about and participate in a Flexible Benefits program.
PDF's require the Adobe Acrobat Reader Plug-In.
Forms
Printable
Online
FSA FORMS
• 2011 Flexible Benefits Reimbursement Voucher
(
PDF
)
(
on-line
)
• 2012 Flexible Benefits Reimbursement Voucher
(
PDF
)
(
on-line
)
• Medical Expense Reimbursement Voucher
(
PDF
)
• Examples Of Expenses Eligible For Reimbursement
(
PDF
)
• Flex Reimbursement Procedures
(
PDF
)
• FSA Letter of Medical Necessity
(
PDF
)
• Flexible Benefits Saving Calculator
(
on-line
)
HRA FORMS
• HRA-Medical Reimbursement Voucher
(
PDF
)
• HRA Reimbursement Procedures
(
PDF
)
Dependent Care Forms
• Dependent Care Registration Statement
(
PDF
)
• Dependent Care Reimbursement Calendar -2011
(
PDF
)
• Dependent Care Reimbursement Calendar -2012
(
PDF
)
Misc. Forms
• Flex Plan Change Form
(
PDF
)
• Direct Deposit Authorization
(
PDF
)
• Lost Check and Replacement Form.pdf
(
PDF
)
• Confidential Employee Survey
(
PDF
)
Questions & Answers
• Claims Reimbursement FAQ
(
PDF
)
(
on-line
)
• Questions And Answers
(
on-line
)
• Request A Quote For Additional Personal Benefits
(
on-line
)
• Calculate Additional Life Insurance Needs
(
on-line
)
Notices
• IMPORTANT NOTICE REGARDING CLIENT PRIVACY
(
PDF
)
• HIPAA NOTICE REGARDING CLIENT PRIVACY
(
PDF
)
New York
PO Box 587
Pittsford, NY 14534
(585) 385-6010
(800) 836-8100
Fax: (585) 248-2488
info@flexbene.com
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