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 PBS FORMS & RESOURCES
 
 •FSA Medical Claim Form
  Request reimbursement from your medical spending account.
 
 •FSA Dependent Care Claim Form
  Request reimbursement from your dependent care (day care) spending account.
 
 •Transportation Claim Form
  Request reimbursement from your transportation or parking spending account.
 
 •HRA Claim Form
  Request reimbursement from your Healthcare Reimbursement Arrangement.
 
 •Premium Reimbursement Claim Form
  Request reimbursement of non-employer sponsored health insurance premiums from your PR spending account.
 
 •Reimbursement Authorization Agreement
  Set-up and authorize direct deposit of your reimbursements. Make changes to your reimbursement method.
 
 •Request for Additional Benefits Cards Form
  Request a PBS Benefits Card for your spouse or a dependent child 18 years and older.
 
 •Participant Change Form
  Update your personal information or make election changes to your flexible spending account.
 
 •Transportation Change Form
  Update your personal information or make election changes to your transportation spending account.
 
 •Health Care Eligible Items List
  A list of expenses that are eligible for reimbursement under your medical flexible spending account starting in 2011.
 
 •Certificate of Medical Necessity
  Some health care services and products are only eligible for reimbursement from your FSA when your doctor or other licensed health care provider certifies that they are medically necessary. This form assists you and your health care provider in supplying information needed to process claims for such products and services.
 
 •Health Care Expense Worksheet
  Get help in determining your annual medical FSA election amount.
 
 •Dependent Care Expense Worksheet
  Get help in determining your annual day care FSA election amount.
 
 •How to set up your Participant Portal Account
  Easy to follow instructions for establishing a new Participant Portal Account.
 
 •How to change your Participant Portal Password
  Easy to follow instructions on how to reset your Participant Portal Password.
 
 •Substantiation Cover Sheet
  If you submitted your Reimbursement Request via our Online Claims Submission (OCS) tool, use this document to forward your receipts. You will only need to utilize this version of the document if you have problems accessing the version that is provided by the OCS process.
 
 •Cardholder Dispute Procedures
  Instructions and forms for disputing PBS Benefits Card transactions.
 
 •Privacy Disclosure Notice
  Read about how we keep your information private.
 
 
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