Forms & Documents

Debit Card Overview

Debit Card Overview for participants enrolling in a Health Care FSA.

Claim Form

Claim form for participants.

Day Care FSA Services Contract

If you want your monthly day care claim to be automatically filed each month, please complete this form.

Orthodontia Contract

Use this form to set up your monthly orthodontia payments as a recurring Health Care FSA claim.

Letter of Medical Necessity

Certain expenses require a provider’s authorization in order for them to be eligible for reimbursement. Complete this form for expenses that require a provider’s authorization.

Direct Deposit and Debit Card Form

If you would like to enroll in direct deposit for your reimbursements, or to request n debit card, please complete this form and return it to Navia Benefit Solutions.

HIPAA Release Form

If you would like to have another individual be able to call Navia Benefit Solutions to discuss your benefits and detailed information about your account, please complete this form.