About Our Forms

You deserve fast answers, fast claims, and Web self-service. That's why we've created forms that provide the information you need, and are easy to use and understand.

If you need any assistance contact us 24/7/365 at 877.933.3539.

To view or print the PDF files, you'll need a free utility called Adobe Reader.

General Info


	What is a Cafeteria Plan?
	What is a MERP or HRA?
	What is COBRA?
	Get Free Acrobat Reader
	Contact Us

General Forms

		pdf
	HIPAA Authorization for Release
	Change of Address Mailing Address/Email Address Changes
	Change of Status Form C.O.S. Qualification Matrix www.changeofstatus.com
	Direct Deposit Authorization
	Fax Cover Sheet
	Leave of Absence Form
	Medical Necessity Letter
	Mileage Report
	Over-the-Counter Medical Guidelines
	Claim Form
	IIAS Merchant List Link

Flexible Spending Account (FSA) Forms
Section 125 Forms

		pdf
Claim Forms
	Recurring Claims Information
	Claim Form
	eflex Card Receipt Form

Dependent Care Tools
	Dependent Care Worksheet
	Dependent Care Contract
	Form 2441 Dependent Daycare Tax Filing Form

Employee Planning Tools and Resources
	FSA Brochure
	FSA Frequently Asked Questions
	FSA Planning Worksheet
	Enrollment Form - Paper
	Health Care Expenses Table
	IRS Publication 502 (Expenses for HSA, HRA, Flex)
	IRS Publication 503 (Daycare)

eflex Debit Card Tools
	FSA Debit Card Instructions
	HRA Debit Card Instructions
	Request Additional eflex Debit Card (You will receive your card in 10 days.)
	eflex Card Receipt Form

Limited Purpose FSA Forms
	Limited Purpose FSA Employee Education Flyer
	Limited Purpose FSA Claim Form

Health Reimbursement Arrangement (HRA) Forms
Section 105 Forms

		pdf
	HRA Change of Status
	HRA/MERP Claim Form
	HRA/MERP Enrollment Form
	HRA/MERP Termination Form

Health Savings Account (HSA)

		pdf
	HSA Additional Debit Card Request
	HSA Beneficiary Change/Spousal Consent
	HSA Death Distribution Request
	HSA Direct Deposit Enrollment/Change
	HSA Distribution Request
	HSA Contribution
	HSA Enrollment Form
	HSA Guide
	HSA Information Authorization
	HSA Information Change Notification
	HSA Power of Attorney Form

COBRA Forms

COBRA forms are available at www.eCOBRA.com.

You must have your Employer Account Log On (username and password), to access the forms. If you have lost or forgotten your username or password, please contact a COBRA Specialist at COBRA@eflexgroup.com or call us at 608.268.5133.

Transportation/Mass Transit Forms

		pdf
	Transit Employee Education Flyer
	Transit/Parking Enrollment Form

En Español

		pdf
	Educativa para Empleado Employee Education
	Referencia de Medicamentos Sin Receta Over-the-Counter Reference
	Preguntas con mas Frequencia FSA Frequently Asked FSA Questions
	Forma de Inscripcion de FSA FSA Enrollment Form
	Circular Educativa para Tarjeta Debito Employee Debit Card Education Flyer
	Parking de Tránsito Formulario de Inscripión Parking Transit Enrollment Form (Spanish)
	Cuenta FSA para el Cuidado de Dependientes Dependent Care FSA Flyer
	Reclamos Recurrentes Recurring Claims Information
	Contrato de Cuidado de Dependientes Dependent Care Contract