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General Information
Worksheet
Over-the-Counter Ruling change
About Change In Election
May You Change Your Elections
Dependent Care Expenses
Orthodontia Example
Internal Revenue Service Publication 502
Internal Revenue Service Publication 503
Internal Revenue Service Form W-10
Internal Revenue Service Form 2441
Internal Revenue Service Instructions for Form 2441
Adoption Assistance Info Sheet
Examples of Qualified Over-the-Counter Expenses
Examples of Qualified Health Care Expenses
Secure Claims Submission Option
Claim Forms
Health Care 'Fill-In' Claim Form*
Health Care Claim Form*
Dependent Care 'Fill-In' Claim Form*
Dependent Care Claim Form*
Qualified Transportaion Claim Form*
Health Premiums Claim Form*
(This is for Individual policies only - not employer provided coverage)
Adoption Assistance Claim Form*
General Forms
Direct Deposit Authorization*
Change In Status Form*
Letter of Medical Necessity*
Release of Information Authorization*
Termination Notification Form*
Client Specific Forms
Maniilaq HRA Claim Form*
*Upon downloading the claim forms, please include your employer name, fill out the form and submit to Benefit Administration Company using the information towards the bottom of the form.
**All of these forms require Acrobat© Reader software. You can download it at .
Click the button below to download.
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