Forms

 

TO SUBMIT A REQUEST FOR FLEX PLAN REIMBURSEMENT:

Submit a signed and dated claim form along with substantiation of the expense. Substantiation must show:

  • Actual Dates of Service
  • Service Provider’s Name
  • Family Member Receiving Service
  • Type of Service Performed
  • Dollar Amount for Which You are Responsible After Insurance Has Paid
  • Signature of the Day Care Provider (if claiming daycare)



COPIES OF CHECKS, CHARGE CARD RECEIPTS, BANK ACCOUNT STATEMENTS, 
PERSONAL COMPUTER PRINT OUTS, CASH REGISTER RECEIPTS (except OTC meds), 
PAID ON ACCOUNT RECEIPTS ARE NOT ALLOWED BY THE IRS AS SUBSTANTIATION







All of the below listed forms are in PDF format. Please download the file(s) needed and either print or save.



Flexible Spending Account (FSA)
Plan Reimbursement Claim Form
Health Reimbursement Arrangement (HRA) Claim Form
Health Savings Account (HSA)




Debit Card Form

TakeCare™ Debit Card Order Form
(Must be sponsored by your Employer)

IRS 720 Form and Instrucutions

 

Automated Account Hotline (913) 789-4600

Customer Service: (800) 447-1690

Report a Lost or Stolen TakeCare™ Debit Card: (866) 679-7649

Fax: (800) 123-4566

By Mail: Compensation Consultants, Ltd.
PO Box 720
Cloquet, MN 55720