| Flexible Spending Accounts (FSA) |
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| • | Enrollment Form |
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| • | Request Reimbursement Form: Health Care and Dependent Care reimbursement request form |
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| • | Direct Deposit Form: For direct deposit of reimbursements (available only if your employer uses Electronic Funds Transfer to deposit your FSA contributions) |
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| • | Enrollment Kit (Non Flex Card): Overview of the FSA and benefits of participation |
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| • | FSA Plan Information: Answers to common questions about the Health Care and Dependent Care FSA |
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| • | Estimated Expenses Worksheet: Helps you estimate your annual FSA expenses |
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| • | Expenses Listing: Summary of eligible and ineligible FSA Health Care and Dependent Care expenses |
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| • | Enrollment Kit (with the EBS Flex Card): Describes the Flex Debit Card for payment of FSA expenses directly to the provider. |
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| • | EBS Flex Card Information |
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| • | Limited FSA Claim Form: Claim reimbursement request form to be used with a High Deductible Health Plan with an HSA. |
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| • | Certificate of Medical Necessity |
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| • | Kodak claim form |
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| • | Request and Additional Flex Card : Please complete the form and return to EBS |
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Transit/Parking Reimbursement Accounts |
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| • | Reimbursement Request Form: Transit and Parking reimbursement request form |
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| • | Direct Deposit Form: For direct deposit of reimbursements (available only if your employer uses Electronic Funds Transfer to deposit your contributions) |
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| • | Enrollment Form: For annual enrollment and changes and a brief summary of allowable expenses. |
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Miscellaneous Forms |
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| • | Authorization to Release Information: A participant, or covered dependent, may obtain information regarding his or her coverage. All other requests received require written authorization from the participant prior to the release. |
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Section 105(h) Health Reimbursement Accounts |
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| • | Reimbursement Request Form: Health Reimbursement Account reimbursement request form |
