Forms

Note: Forms are in PDF format. You will need Adobe® Acrobat Reader to read PDF files.

Claim Forms

• Complete and print from your computer
  If input fields are not highlighted, check "Highlight Fields" in the upper right corner, then use your tab key to move from field to field.
• Fillable Commuter Expense Reimbursement Account (CERA)
• Fillable Dependent Care Account (DCA)
• Fillable FSA Healthcare Account (FSA)
• Fillable Health Reimbursement Account (HRA)

• Print and complete by hand
• Claim Form - Commuter Expense Reimbursement Account (CERA)
• Claim Form - Dependent Care Account (DCA)
• Claim Form - FSA Healthcare Account (HCA)
• Claim Form - Health Reimbursement Account (HRA)

Flexible Spending Accounts Enrollment and Change Applications

Choose the form that matches your company’s benefit options.

• Plans with a MasterCard Debit Card
• Plans with ODS Autopay
• Plans with both the Debit Card and Autopay
• Plans with neither a Debit Card nor Autopay

Other Enrollment and Change Applications

• Commuter Expense Reimbursement Account Application
• Health Reimbursement Arrangement Account – Plan with AutoPay
• Health Reimbursement Arrangement Account – Plan with Benefits Card

Other Forms

• Certification of Dependent Status
• Direct Deposit Form
• Letter of Medical Necessity
• Authorization to Disclose Information Q&A
• Authorization to Disclose Information Form

Send forms to:
Flexible Spending Accounts Administration
P.O. Box 67230
Portland, OR 97268-1230
888-249-5058 Fax toll free