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VitaFlex Forms

Provided below is a complete list of VitaFlex forms and a brief description of their use.

Medical FSA Forms
Health FSA Claim Form	Use this form to submit medical claims for reimbursement. If your plan offers a grace period, be sure to mark which Plan Year you wish to apply the claim. If the VitaFlex Debit Card was used to pay for the claimed expense, check the box marked “Debit Card.”
Orthodontia Claim Form	Orthodontia claims require additional treatment plan information in order to be approved. This hybrid claim form can be used to outline the details of the treatment plan. All future claims toward the treatment will not require this form again, and can be made using a standard Medical Claim Form. (Please reference the included guidelines for additional information)
Over-the-Counter Item Clarification	If a claim is made for an over-the-counter item, the receipt must clearly indicate the name of the product being purchased. If the product name is not easily determined from looking at the receipt, use this form to clarify the name of the item. The form must be signed by the merchant for confirmation.
Over-the-Counter Prescription Form	As of January 1, 2011, any claims for over-the-counter medicines, drugs or biologicals require a prescription from a doctor to be deemed eligible. Use this form by taking it to a physician to fill out in advance of any claims for over-the-counter medicines, drugs or biologicals.
Statement of Medical Necessity	Use this form to document the medical necessity of certain specific items or services (when necessary). This form must be signed by a licensed physician or provider. (Please reference the included guidelines for additional information)
Dependent Care FSA Forms
Dependent Care Claim Form	Use this claim form to submit dependent care claims for reimbursement. This form can be used as third party substantiation if it is signed by the provider in the “Provider Receipt” area.
Other Forms
Account Authorization Form	Participants may use this form to add or remove contacts who are allowed access to their FSA account and protected health information.
Direct Deposit Form	If your plan includes the option for reimbursement of your claims via direct deposit, then this form can be used to add, remove, or change bank account information.
Debit Card Request Form	For plans offering the VitaFlex debit card option, this form can be used to request an additional debit card for a spouse or qualified dependent.
Affidavit of Dependent Status	This form must be submitted by the participant in order to make medical FSA claims for a tax dependent who is not a child or spouse. A new affidavit must be completed each Plan Year.
Affidavit of Domestic Partnership	This form must be submitted by the participant in order to make medical FSA claims for a domestic partner. A new affidavit must be completed each Plan Year.

VitaFlex Forms

VitaFlex Forms

Medical FSA Forms

Dependent Care FSA Forms

Other Forms