resources

Forms


Participant Forms


FSA Forms

Form Title

Form Description

Claim Form Paper claim form for FSA Medical, Dependent Care, and HRA submission
How to Submit an FSA Claim Instructions on submitting FSA Medical and Dependent Care claims
Automatic Deposit Form Authorization form for automatic deposit of FSA and HRA reimbursements into your checking or savings account
Q&A Booklet Packet includes Q&A, how to submit an FSA claim, auth form for auto reimbursement deposit, FSA enrollment form
Change of Status Form FSA Change of Status form; FSA & HRA Termination Notification
Letter of Medical Necessity Attending physician form to be completed to confirm medical necessity of a procedure for certain conditions
FSA Enrollment Form FSA Enrollment form
Instructions on How to Submit a claim online Step by Step Online claim filing instructions for Transit, Parking, Dependent Care, FSA, and HRA
Instructions on how to use the myRSC mobile app Mobile app user Quick Start Guide for myRSC

HRA Forms

Form Title

Form Description

Claim Form Paper claim form for FSA Medical, Dependent Care, and HRA submission
MySource Substantiation Form Used for myRSC Debit Card to validate card purchases according to the IRS regulations.
How to Submit an HRA Claim Instructions on how to submit for HRA reimbursement
Automatic Deposit Form Authorization form for automatic deposit of FSA and HRA reimbursements into your checking or savings account
Letter of Medical Necessity Attending physician form to be completed to confirm medical necessity of a procedure for certain conditions
Instructions on How to Submit a claim online Step by Step Online claim filing instructions for Transit, Parking, Dependent Care, FSA, and HRA
Instructions on how to use the myRSC mobile app Mobile app user Quick Start Guide for myRSC

HSA Forms

Form Title

Form Description

HSA Online Employee Enrollment Process HSA online enrollment instructions including assignment of password; bank set-up; electronic funds transfer; debit card application; investment options;
HSA Today Salary Reduction Agreement Authorizes employer to reduce salary by the amount of the HSA contributions

Other Forms

Form Title

Form Description

Ortho Worksheet Provides orthodontic reimbursement guidelines including calculations to assist in determining the amount eligible per plan year

Employer Forms


FSA Forms

Form Title

Form Description

Employer Enrollment Checklist Planning checklist for FSA Open Enrollment
FSA Enrollment Form FSA Enrollment form for Employees
FSA Q&A Booklet Packet includes Q&A, how to submit an FSA claim, auth form for auto reimbursement deposit, FSA enrollment form
Employer Payroll Contribution Spreadsheet Template for FSA Payroll Deductions
Instructions on how to submit a claim online Step by Step Online claim filing instructions for Transit, Parking, Dependent Care, FSA, and HRA
Instructions on how to use the myRSC mobile app Mobile app user Quick Start Guide for myRSC
Change of Status FSA Change of Status form; FSA & HRA Termination Notification

HRA Forms

Form Title

Form Description

HRA Enrollment Spreadsheet Template for HRA Enrollment/Implementation
Change of Status FSA Change of Status form; FSA & HRA Termination Notification
Instructions on how to submit a claim online Step by Step Online claim filing instructions for Transit, Parking, Dependent Care, FSA, and HRA
Instructions on how to use the myRSC mobile app Mobile app user Quick Start Guide for myRSC