If you pay out-of-pocket for pre-tax expenses and don’t have an itemized receipt, you can include these completed forms when you file a claim from your Forma account.
We cannot accept self-made receipts. Please complete the applicable form if an itemized receipt cannot be provided.
You can also use this form for expenses paid with your Pre-tax Forma Card when asked for substantiation.
Attach the form along with your other supporting documents such as an emailed invoice, bank statement, or other proof of payment when filing your claim.
Please note that only completed services can be reimbursed. Please list service start and end dates on the form so that Forma’s claim review team can better verify eligibility.