Resources & Forms

HIPAA Authorization Form (Use & Disclosure of Protected Health Information)
Complete and submit this form if you wish to allow any person other than yourself permission to contact our Service Center about your benefits.  Our specialists cannot disclose information about you to any individual(s) other than yourself if an authorization form is not on file.

HIPAA Privacy Policy
This document outlines the HIPAA Privacy Rule and includes our policy on how we use Protected Health Information (PHI).

FSA Reimbursement Claim Form
Use this form and submit it along with your expense receipts to be reimbursed from your FSA.

Qualified Transportation Expense Plan Reimbursement Claim Form
Use this form and submit it along with your transit and/or parking expense receipts to be reimbursed from your account.

Health Reimbursement Account (HRA) Claim Form
Use this form and submit it along with your expense receipts to be reimbursed from your HRA.

FSA Direct Deposit Authorization
If you are enrolled in an FSA and would like to have your reimbursements deposited directly into a bank account, please visit www.MyFlexDollars.com.

Request a Benny™ Prepaid Benefits Card
If you are a Benny™ cardholder and would like to request replacement or additional cards, please visit www.MyFlexDollars.com.

Certification of Medical Necessity
(Medical/Health Care FSA participants only)

This form can be used to request reimbursement from your FSA for expenses that typically do not qualify for reimbursement from an FSA if the expense is tied to medical necessity.  Effective January 1, 2010, FSA participants must use this form to be reimbursed for over-the-counter medicines and drugs.  As of January 1, 2010, these expenses cannot be reimbursed from an FSA unless they were incurred out of medical necessity.

FSA Calculator
The FSA Calculator will help you determine an appropriate Annual Health Care FSA Contribution Amount. And, it will automatically calculate estimated tax savings based on your Annual FSA Contributions.

IIAS Merchant List
This list identifies merchants using an Inventory Information Approval System (IIAS) capable of identifying FSA/HRA-eligible expenses at the point of service.  When you use the Benny Prepaid Benefits Card to pay for qualifying expenses at these merchants, you will not be requested to submit receipts to validate your expense!




Get in touch. 1-800-307-0230

A Baker Tilly Company

Vantagen
1200 Abington Executive Park, Clarks Summit, PA 18411 | Phone: 570.586.0480 | Fax: 866.405.0402

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