Claims and FSA Forms
- Flexible Compensation Plan Employee Authorization Agreement
- Health Reimbursement Arrangement (HRA) Payment Request Form
- PharmaCare Direct Member Reimbursement Form
- Request for Reimbursement from Employee Flexible Compensation Account
- Supplemental Claim Statement
- Flex Debit Card Receipt Form
- Benny Card Handout on OTC Purchases
- FSA List of Eligible-Ineligible Items Rev. 4--2011
General Notices for Group Health Plans
Because of the fluid nature of the Patient Protection and Affordability Act (PPACA) regulations being modified, please note that these forms and the information contained herein are subject to change at any time. The information should not be considered legal advice. If you have any questions about the Notices below, please call us at 704-525-9666 to discuss.
- Model Special Enrollment Notice
- Dependent Opportunity to Enroll to Age 26
- General Notice of Pre-Existing Condition
- Grandfathered Plans Notice
- HIPAA Notice of Privacy Instructions
- HIPAA Notice of Privacy Practices
- Notice of Newborns and Mothers Protections Act
- Notice of Women's Health and Cancer Rights
- Notice of PPACA Patient Protection
- Notice of No Lifetime Limit
- National Medical Support Notice Part B
- QMCSO Part A
- Notice of MHPEA
- Notice of Non-Creditable Coverage Medicare Part D
- Notice of Creditable Coverage Medicare Part D
- Notice of Wellness Program
- ACA Exchange Notice to Employees with Health Plan
- ACA Exchange Notice to Employees without Health Plan