PBS FORMS
Participants
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FSA_Medical_Claim_Form.pdf
Request reimbursement from your medical spending account.
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FSA_Dependent_Care_Claim_Form.pdf
Request reimbursement from your dependent care spending account.
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Transportation_Claim_Form.pdf
Request reimbursement from your transportation or parking spending account.
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Premium_Reimbursement_Claim_Form.pdf
Request reimbursement of non-employer sponsored health insurance premiums from your PR spending account.
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Transportation_Changes.pdf
Update your personal information or make election changes to your transportation spending account.
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Direct_Deposit_Auth.pdf
Set-up and authorize direct deposit of your reimbursements.
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Spouse_Card_Request.pdf
Request a PBS Benefits Card for your spouse.
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Participant_Changes.pdf
Update your personal information or make election changes to your flexible spending account.
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Eligible_Expenses.pdf
A list of expenses that are eligible for reimbursement under your medical flexible spending account.
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Eligible_OTC.pdf
A list of over-the-counter medicines and products that are eligible for reimbursement.
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Certificate of Medical Necessity
Some health care services and products are only eligible for reimbursement from your FSA when your doctor or other licensed health care provider certifies that they are medically necessary. This form assists you and your health care provider in supplying information needed to process claims for such products and services.
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Expense_Worksheet.pdf
Get help in determining your annual FSA election amount.
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Substantiation_Cover_Sheet.pdf
If you submitted your Reimbursement Request via our Online Claims Submission (OCS) tool, use this document to forward your receipts. You will only need to utilize this version of the document if you have problems accessing the version that is provided by the OCS process.
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Cardholder_Dispute_Procedures.pdf
Instructions and forms for disputing PBS Benefits Card transactions.
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Privacy_Disclosure_Notice.pdf
Read about how we keep your information private.
Click here to download HCA Affiliate Participant forms.
