The Vita Companies

What's VitaFlex^®?

Debit Card Tools

VitaFlex^®: Forms and Links

Medical Forms

	Claim Form - Medical (PDF)
	Claim Form – Medical Debit Card (PDF)
	Claim Form – Medical Grace Period (PDF)
	Claim Form – Medical Grace Period & Debit (PDF)
	Claim Form – Orthodontia (PDF)
	Mid-Year Exception - Medical (PDF)
	Claim Form - Over-the-Counter Item Clarification (PDF)

	Statement of Medical Necessity (PDF)

Dependent Care Forms

	Claim Form - Dependent Care (PDF)
	Mid-Year Exception - Dependent Care (PDF)

Other Forms

	Account Correspondence Authorization Form (PDF)
	Bank Authorization Form (PDF)
	Leave of Absence Form (PDF)
	Leave of Absence Participant Instructions (PDF)
	Second Debit Card Request Form (PDF)

Useful FSA Links

	IRS Publication 502, "Medical and Dental Expenses"* (PDF)
	IRS Publication 503, "Child and Dependent Care Expenses"* (PDF) * Please note that there could be some items or services that are ineligible under IRC Section 125. Please contact Vita Administration Company for further details.