Flexible Benefit Form Downloads Download Form Description Flexible Spending Account (FSA) Reimbursement Request Form This form is for both Health and/or Dependent Care Reimbursement FSA Claims. Instructions are liste d on the second page of this form and it can be filled out online and printed with Adobe Acrobat Reader. Health Reimbursement Account (HRA) Reimbursement Request Form This form is specifically for Employer Funded HRA claims. Instructions on how to complete this form are listed on the second page of this form. It can be filled out online and printed with Adobe Acrobat Reader. Health Flexible Spending Account Eligible Expenses This is a list of eligible expenses for the Health FSA Plan. It is not intended to be complete, however, it illustrates the type of health care expenses that can be claimed as part of the Plan. (source: IRS Publication 502) Over-the-Counter Eligible Expenses This is a list of over-the-counter (OTC) expenses that are eligible for Health FSA reimbursement. FSA Worksheet Print this worksheet and complete it to estimate how much you should set aside for a Health or Dependent Care FSA. You can also use our FSA Calculator to estimate how much an FSA could save you. Dependent Care Expense Worksheet Should you consider a Dependent Care FSA or stick with the Federal Dependent Care Tax Credit. This worksheet can help you determine which option might work best for you. You can also use our FSA Calculator to estimate how much a Dependent Care FSA could save you. ©2008 Combined Services LLC, All rights reserved.Privacy Policy