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Flexible Spending Account Forms Employer Applications COBRA Continuation Election for Medical Reimbursement Accounts #H-8373  (148KB) Health Reimbursement Account Employer Application including Flex Debit Card #H-8383 (261KB) Health Reimbursement Account (HRA) Employer Application #H-8364  (283KB) Premium Only Plan Application #M-53216  (174KB) Reimbursement Account Flexible Benefits Employer Application #H-8305  (360KB) Reimbursement Account Flexible Benefits Employer Application including the Flex Debit Card #H-8381  (331KB)

Enrollment Forms

• Request for Reimbursement #H-8303  (397KB) 
• Request for Reimbursement (Spanish) #H-8371  (165KB) 
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory Combination #H-8754  (396KB) 
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory with Debit Card Authorization #H-8772  (344KB) 
• Employee Reimbursement Account & Non-Mandatory Pre-Tax Premium Payment with Debit Card Authorization #H-8774  (367KB)
• Health Reimbursement Account #H-8767  (235KB)
• Health Reimbursement Account with Debit Card Authorization #H-8382 
   (143KB)
• Pre-Tax Premium Payments and Employee Reimbursement Accounts Change Form #H-8764  (228KB)
• Pre-Tax Premium Payments Mandatory Enrollment Form #H-8707  (196KB)
• Pre-Tax Premium Payments Non-Mandatory #H-8711  (208KB)

Administrative Forms for Employees

• View and download employee flex forms

Educational Materials

• Order Blue Priority Flex^SM member education materials on the Employer Toolkit