Flexible Spending Account Forms
Employer Forms
Flexible Spending Account Employee Enrollment.pdf
Form to complete for employee to be enrolled in Medical and/ or Dependent Care FSA
Limited Flexible Spending Account Employee Enrollment.pdf
Form to complete for employee to be enrolled in Medical, Limited, and/ or Dependent Care FSA
Flexible Spending Account Change in Status.pdf
Form to report an employee change in status and corresponding election adjustment for the Flexible Spending Account
Employee Forms
Employee Claim Form for Flexible Spending Account.pdf
Form to complete to file for reimbursement of qualified expenses under your Medical, Limited, and/or Dependent Care Flexible Spending Account
Employee Claim Form for Flexible Spending Account.pdf
Form to complete to file for reimbursement of qualified expenses under your Medical, Limited, and/or Dependent Care Flexible Spending Account
ACH Direct Deposit Form.pdf
Form to complete and return to BMS to set up ACH Direct Deposit of reimbursements
Flexible Spending Account Worksheet.pdf
Worksheet to help calculate potential participant contribution and savings for the Flexible Spending Account
Flexible Spending Account Qualified Expenses List.pdf
Broad list of potentially qualifying expenses for reimbursement from the Flexible Spending Account
FSA Eligilibility List
Valid for FSA, HSA, and general HRA expenses.
Dependent Care Reimbursement Account
Employer Forms
Dependent Care Reimbursement Account Employee Enrollment.pdf
Form to complete for employees enrolling only in the Dependent Care FSA
Employee Forms
Employee Claim Form for Dependent Care Reimbursement Account.pdf
Form to complete to file for reimbursement of qualified childcare expenses under your Dependent Care Flexible Spending Account
Health Reimbursement Arrangement
Employer Forms
Health Reimbursement Arrangement Bridge Plan Employee Enrollment Form.pdf
Form to complete for employee to be enrolled in Bridge HRA
Employee Forms
Employee Claim Form for Health Reimbursement Arrangement.pdf
Form to complete to file for reimbursement of qualified expenses under your HRA
ACH Direct Deposit Form.pdf
Form to complete and return to BMS to set up ACH Direct Deposit of reimbursements
Health Reimbursement Arrangement Comprehensive Plan Employee Enrollment Form.pdf
Form to complete for employee to be enrolled in Comp HRA
Health Savings Account Forms
Employer Forms
Employee Claim Form for Health Savings Account.pdf
Form to complete to file for reimbursement of qualified expenses under your HSA
Employee Forms
Health Savings Account Employee Enrollment Form.pdf
Form to complete for employee to be enrolled in Health Savings Account
Health Savings Account Employee Contribution Change Form for HSA Bank.pdf
Form to report an employee contribution change for the HSA Bank Health Savings Account
Transit Plan Forms
Employer Forms
Transportation Plan Employee Enrollment Form.pdf
Form to complete for employee to be enrolled in Transit reimbursement account
Employee Forms
Employee Claim Form for Transit Plan.pdf
Form to complete to file for reimbursement of qualified transportation expenses under your Transit Plan
COBRA and Retiree Billing Forms
Employer Forms
COBRA Employer Qualifying Event Notification.pdf
Form to complete to report a Qualifying Event and generate a COBRA Qualifying Event notice
COBRA New Hire Notification.pdf
Form to complete to report a new COBRA eligible employee and generate a COBRA Initial Notice