the MGIS companies

Employee Forms

FSA ACCOUNTS: HCRA (Medical) and DCRA (Dependent Daycare)
HCRA: (Medical FSA) – Information and Forms

• REIMBURSEMENT: HCRA Medical Reimbursement (FSA-HCRA Medical Reimbursement Request)
• REIMBURSEMENT: HCRA Medical Reimbursement (FSA-HCRA Medical Reimbursement Request) (MS Word format)

DCRA: (Dependent Daycare FSA) – Information and Forms

• REIMBURSEMENT: DCRA Dependent DayCare Reimbursement(FSA-DCRA Dependent Care Reimbursement Request)
• REIMBURSEMENT: DCRA Dependent Care Reimbursement Request - Electronic (MS Word format)

HRA: (Health Reimbursement Arrangement – Employer-Sponsored Plan)

• REIMBURSEMENT: HRA (Healthcare Reimbursement Arrangement Reimbursement Request)
• REEMBOLSO: HRA (Petición de Reembolso de Arreglo de Reembolso de asistencia sanitaria)
• REIMBURSEMENT: HRA (Healthcare Reimbursement Arrangement Reimbursement Request) - Electronic (MS Word format)

LPFSA (Limited-Purpose FSA) – Information and Forms

• REIMBURSEMENT: LPFSA Reimbursement (Limited Purpose FSA Reimbursement Request)

PREMIUM REIMBURSEMENT ACCOUNT (PRA) – Information and Forms

• REIMBURSEMENT: PRA Reimbursement Request Form

CBA: (Commuter / Transportation) – Information and Forms

• REIMBURSEMENT: CBA Commuter Benefits Reimbursement (FSA-CBA Commuter Benefits Account Reimbursement Request)

OTHER FORMS AND PLAN INFORMATION

• FORM: HIPPA Authorization form
• FORM: Card Transaction Receipt Coversheet
• FORM: Card Transaction Receipt Coversheet - Electronic (MS Word format)
• FORM: Additional Card Request
• DIRECT DEPOSIT SET-UP: Online set-up with on-screen help
• LIST: Common Flex-Covered Expenses

Employer Forms

FSA ACCOUNTS: HCRA (Medical) and DCRA (Dependent Daycare)

• ENROLLMENT: FSA Election Form (Medical and/or Dependent Daycare Election Form)
• MATRICULACIÓN: FSA Paquete de Matriculación de empleado (breve)
• ENROLLMENT: DCRA (Dependent Care) Worksheet

HRA: (Health Reimbursement Arrangement – Employer-Sponsored Plan)

• ENROLLMENT: HRA/FSA Election Form (HCRA, DCRA and HRA)
• ENROLLMENT: HRA Election Form (HRA Only)

LPFSA (Limited-Purpose FSA) – Information and Forms

• ENROLLMENT: LPFSA Election Form (Limited Purpose Flexible Spending Account)

PREMIUM REIMBURSEMENT ACCOUNT (PRA) – Information and Forms

• ENROLLMENT: PRA Election Form (HCRA, DCRA and PRA: Premium Reimbursement Account)

CBA: (Commuter / Transportation) – Information and Forms

• ENROLLMENT: CBA Information Sheet (Commuter Benefits Account)
• ENROLLMENT: CBA Election Form (Commuter Benefits Account)

OTHER FORMS AND PLAN INFORMATION

• FORM: HIPPA Authorization form
• FORM: Election Change / Change in Status Form
• FORM: Card Transaction Receipt Coversheet
• FORM: Card Transaction Receipt Coversheet - Electronic (MS Word format)
• FORM: Additional Card Request
• LIST: Common Flex-Covered Expenses