AFA - Flexible Spending Account & Section 125 Forms

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Flex & Section 125

»	Flexible Spending Account & Section 125 Forms

Reimbursement Forms
Section 125 Customer Information for Plan Administrators

For additional reimbursement information visit the Frequently Asked Questions page or view the list of Common Expense Reimbursement Requests and Eligibility Guidelines.

Reimbursement Forms

Forms displayed with this image are type-in forms.
Please complete and print the form, attach any additional documentation that may be required, and send to the address or fax number shown on the form. All documents are in Adobe PDF format. You will need the free Adobe® Reader® to view these documents. We recommend version 6.0 or newer. You can upgrade here.

For The Educational Community:

FLEX: Flexible Spending Account Information Packet

FLEX: Authorization for Automatic Deposits

FLEX: Health FSA/Unreimbursed Medical Expense Reimbursement Voucher

FLEX: Dependent Day Care Expense Reimbursement Voucher/Provider Acknowledgment Form

FLEX: Medical Travel Log/Expense Reimbursement Voucher

FLEX: PHI Authorization Form

Note: This authorization form will need to be completed by the participant in order for American Fidelity to discuss Protected Health Information (PHI), with regards to the Flexible Spending Accounts, with someone other than the participant. This includes your spouse or dependents.

For Business Employees:

FLEX: Flexible Spending Account Information Packet

FLEX: Authorization for Automatic Deposits

FLEX: Health FSA Expense Reimbursement Voucher

Note: Use this reimbursement voucher if you participate in FLEX only.

FLEX: Dependent Day Care Expense Reimbursement Voucher/Provider Acknowledgment

HRA: Expense Reimbursement Voucher

Note: Use this reimbursement voucher if you participate in HRA only.

FLEX/HRA: Expense Reimbursement Voucher

Note: Use this reimbursement voucher if you participate in both FLEX and HRA.

Information for Section 125 Plan Administrators

All documents are in Adobe PDF format. You will need the free Adobe® Reader® to view these documents. We recommend version 6.0 or newer. You can upgrade here.

For Educational Administrators:

Section 125 Administration Guide

For Business Employers:

Section 125 Administration Guide

Section 79-2007

HSA Addition Form

Newsletter - Dec 2008

Newsletter - July 2008