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What's VitaFlex®?
Employee Guide
Debit Card Tools
Forms/Links
Claims How-To
For Employers
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)
Dependent Care Forms
Claim Form - Dependent Care
(PDF)
Mid-Year Exception - Dependent Care
(PDF)
Other Forms
Leave of Absence Form
(PDF)
Leave of Absence Participant Instructions
(PDF)
Bank Authorization Form
(PDF)
Useful FSA Links
IRS Publication 502, "Medical and Dental Expenses"
(PDF)
IRS Publication 503, "Child and Dependent Care Expenses"
(PDF)
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Securities offered through Liberty Group, L.L.C.
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