Printable Forms

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FSA Forms – English

Flexible Spending Account (FSA) Enrollment Brochure

FSA Eligible Expense Listing

FSA Claim Form

Limited FSA Eligible Expense List

Limited FSA Claim Form

FSA Gluten-Free Claim Form

 


FSA Forms – Spanish

Artículo 213 FSA

Plan deReembolso FSA Formulario de Reclamación

 


Direct Deposit Form

Direct Deposit Form

 

Change in Status

Change in Status Form

 

TMA Forms

TMA Budget Tool

TMA Election Form

Transportation & Parking Eligible Expense List

TMA Claim Form

 


TMA Forms – Spanish

TMA Election Form – Spanish

TMA Claim Form – Spanish

 

HSA Forms 

Login to your HSA Employee Portal to make changes and/or access forms that are applicable to your account.

 

HRA Claim Forms 

Login to your Employee Portal and/or the BeneFlexHR Mobile app to file claims and access your account information.

 

Health Care Security Ordinance (HCSO HRA) Forms – English
(San Francisco ONLY)

HCSO HRA Employee Overview

HCSO HRA Full Medical Spend Down Qualified Expenses

Dental/Vision/LTC HCSO HRA Eligible Expenses

How to File a Claim

HCSO HRA Claim Form

HCSO HRA Direct Deposit Form

 

Health Care Security Ordinance (HCSO HRA) Forms – Spanish
(San Francisco ONLY)

HCSO HRA Employee Overview -Spanish

HCSO HRA Full Medical Spend Down Eligible Expenses-Spanish

Dental/Vision/LTC HCSO HRA Eligible Expenses – Spanish

HCSO HRA Claim Form

HCSO HRA Direct Deposit Form – Spanish