| Download |
Form |
Description |
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Flexible Benefit Plan Enrollment Form |
An enrollment form for Health and Dependent Care Flexible Spening Accounts (HFSA and DCFSA)needs to be completed each plan year and upon the change of election with a qualifying event. A pdf of these forms will be provided to you with your Employer's name upon enrollment with Combined Services LLC. Post the pdf on your intranet site or keep it on file with Human Resources for easy access. |
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Dependent Care Worksheet |
This worksheet is to help determine which would be your best tax savings; a Dependent Care Flexible Spending Account or a Tax Credit.
The worksheet is an estimate - for specific details you should consult your tax advisor. |
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Premium Conversion Refusal Form |
Employees who elect to waive participation in the Premium Conversion Plan must complete this form. Your company's Premium Conversion Refusal form is located at the end of your Plan Document. |
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ACH/Direct Deposit & Debit Card mbi Banking Authorization |
The ACH/Direct Deposit Authorization form allows Combined Services LLC automatically debit the employer's account for claims processed each week. This form and the Debit Card mbi Banking Authorization, which automatically debits the employer's account for all debit card transactions processed daily, must both be completed by the employer in order to offer debit cards to participants. These forms can also be used to communicate changes regarding the account. |
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Direct Deposit Authorization Form |
This is an authorization form to have Combined Services LLC (CSLLC) initiate direct deposits to a Health and/or Dependent
Care Flexible Spending Account Participant's checking or savings account. |
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Health and Dependent Care FSA Reimbursement Request Form |
This form is for both Health and/or Dependent Care Flexible Spending Account (HFSA & DCFSA) Claims. Instructions are listed on the second page of this form and it can be
filled out online and printed with Adobe Acrobat Reader. |
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Flexible Spending Account Worksheet |
This worksheet can help you estimate the amount of money you should put into a Flexible Spending Account in order to get
the most of your pre-tax dollars. You can also use our FSA Calculator to compute your tax savings. |
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Health Reimbursement Arrangement (HRA)- Claim Form |
This form is specifically for Employer Funded Health Reimbursement Arrangements. 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. |
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List of Eligible Expenses |
This is a list of eligible expenses for the Health Flexible Spending Account. 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) |
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Over-the-Counter Listing |
This file lists examples of over-the-counter medications that are eligible with a Health Flexble Spending Accounts (HFSA). |
