FSA/HSA Reimbursement Form Download Link HERE.
DCFSA Reimbursement Form/Receipt Download Link HERE.
This form is for reimbursement of any out-of-pocket expenses where your Forma Benefits Card was not used, and you do not have a detailed itemized receipt.
You may use this for documentation for expenses paid with your Forma Benefits Card for substantiation. Please submit this form with your supporting documents, such as an email invoice or bank statements as proof of the payment via the Claims page of your account.
Please be noted that only services that are fully rendered can be reimbursed. Please list out both the service start dates and end dates in the form so the Forma claim review team can better verify the eligibility.
If you have any questions about this, please reach out to our Customer Support Team at email@example.com or send us a live chat message through your Forma mobile app!
For questions regarding pre-tax accounts (HSA, FSA, DCFSA, etc.) you can also reach us by phone at 844-902-2902 Monday through Friday, 8 AM EST - 8 PM EST. We're here to help!