How To Submit A Reimbursement Claim (FSA)
Click here to download a copy of the claim form referenced in this “How To” document.
HSA Account Transfer Form
This form is used to request an HSA Transfer or Rollover from a prior custodian to DataPath Administrative Services. General Information An account transfer, or rollover, is how money or property can be moved into a Health Savings Account (HSA) from a Medical Savings Account (MSA) or existing HSA. The Internal Revenue Code (IRC) limits … More >>
HSA Request for Distribution Form
Complete this form to request a distribution from your Health Savings Account (HSA). Unlike FSA claims, requests for HSA distributions do not require receipts; however you may want to store any associated receipts in the HSAToday ClaimsVault in case they are needed in the future.
Dependent Care Recurring Expense Form
Complete this form to request automatic reimbursement from your Dependent Care Assistance Plan (DCAP) account. Contributions will be reimbursed to you on a per-pay-period basis. By completing this form you will not need to provide continuing documentation. Please complete all fields and include appropriate documentation stating your child will be attending throughout the year or … More >>
Debit Card Request Form (Replacement or Additional)
Complete this form to request replacement of a lost or stolen debit card or to request additional cards for dependents.
Employee Direct Deposit Authorization Form
Use this form to request that a claim reimbursement be deposited directly into your bank account. Instructions for completing this form: Fill in all fields below Attach voided check (no deposit slips) Sign and date form. If the account is not in your name alone, the other account holder must also sign and date form.
