| | PBS FORMS |
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| | • | FSA Medical Claim Form |
| | | Request reimbursement from your medical spending account. |
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| | • | FSA Dependent Care Claim Form |
| | | Request reimbursement from your dependent care (day care) spending account. |
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| | • | Transportation Claim Form |
| | | Request reimbursement from your transportation or parking spending account. |
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| | • | HRA Claim Form |
| | | Request reimbursement from your Healthcare Reimbursement Arrangement. |
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| | • | Premium Reimbursement Claim Form |
| | | Request reimbursement of non-employer sponsored health insurance premiums from your PR spending account. |
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| | • | Reimbursement Authorization Agreement |
| | | Set-up and authorize direct deposit of your reimbursements. Make changes to your reimbursement method.
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| | • | Spouse Card Request Form |
| | | Request a PBS Benefits Card for your spouse. |
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| | • | Participant Change Form |
| | | Update your personal information or make election changes to your flexible spending account. |
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| | • | Transportation Change Form |
| | | Update your personal information or make election changes to your transportation spending account. |
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| | • | Eligible Expenses List |
| | | A list of expenses that are eligible for reimbursement under your medical flexible spending account. |
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| | • | Eligible Over-the-Counter List |
| | | 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 |
| | | Get help in determining your annual FSA election amount. |
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| | • | Substantiation Cover Sheet |
| | | 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 |
| | | Instructions and forms for disputing PBS Benefits Card transactions.
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| | • | Privacy Disclosure Notice |
| | | Read about how we keep your information private. |
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