Flex (PBA)

Form

Description

This form details many items that are eligible to be taken from the FSA and contains a worksheet to help determine how much to withhold.

Fsafeds.com lets you search FSA eligibility and lists if items need additional documentation to be eligible. Click here for link directly to FSA eligible expenses search.

Additional Resource:

FSAstore.com is an online marketplace for FSA-eligible products.

PBA Flex Claim Reimbursement Form

PBA Flex Medical Necessity Form

PBA Flex Dependent Care Reimbursement Form

Flex Election Form

Complete this form to submit claims for unreimbursed medical/dental and dependent care expenses from your flexible spending account.

Certain items may be considered eligible expenses if deemed Medically Necessary by a prescribing physician. Have your provider completed this form.

You can also submit claims online at www.pbaclaims.com or on the PBA Flex App. This is the recommended and fastest way to submit claims for reimbursement.

Use the Flex Election Form to verify where you would like your Think Healthy contribution to go. Flex Spending or Deferred Compensation.