Claim Forms
A participant may utilize either form below to submit claims. The General FSA Claim form does not include the DCAP section and allows more lines to write in additional medical expenses for which you are claiming reimbursement.
Please note that if you are using Acrobat Version 4, the PDF form will display some odd numbers in the dollar amount column. To eliminate these numbers, use the Get Adobe Reader link below to update to the newest version. There is no cost for upgrading to the newest version of Acrobat Reader.