Forms

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Flexible Spending Account Reimbursement Request Forms

• Medical FSA
• Dependent Care FSA
• Parking Reimbursement Account

Flex Debit Card Materials

• What You Need to Know About Your Flex Debit Card
• Certified IIAS Merchant List
• Medical Reimbursement Request / Substantiation Form
• Flex Debit Card Refund Form

HRA Reimbursement Request Forms

• HRA Reimbursement Request

Customized Reimbursement Request Forms

• Boston College Pay-The-Provider Request Form
• Children's Hospital Tuition Assistance Application and Checklist
• Harvard University Tuition Assistance Plan Form
• Harvard University HUCTW Tuition Assistance Plan Form

ACH Withdrawl Authorization (For Cobra / Billing Premiums)

• ACH Authorization Form
• ACH Authorization Q & A

Direct Deposit Authorization

• Direct Deposit Authorization Form
• Direct Deposit Q & A

HIPAA

• Crosby HIPAA Authorization

Other Documents

• List of Eligible Medical Flexible Spending Account Items
• Tax Savings Brochure
• Sample Explanation of Unreimbursed Claims

If you would like to obtain other forms, or require assistance, please contact us:
Email: servicecenter@crosbybenefits.com
Phone: 800-462-2235
Fax: 617-928-0001