BENEFIT INFORMATION SERVICES, INC.

EMPLOYERS

EMPLOYEES

Flex Forms

To view or print the forms for the providers below you will need the free Adobe® Acrobat® Reader™. It works on a wide range of computer platforms, including Macintosh and Windows. If you don't already have it, you need to download and install the appropriate version for your computer. If you are not sure whether you have Acrobat Reader, please contact your technical support people.

Form 5500
As part of Benefit Information Services, Inc. (BIS) we will complete the required IRS Form 5500 and Summary Annual Report for our clients on an annual basis.

FSA Enrollment Kit
Access the FSA Enrollment Kit for information on flexible spending plans, rules and regulations, calculating your reimbursement account deduction, requesting a reimbursement and the reimbursement schedule.

FSA Reimbursement Request (Claim) Form
Complete this form and submit it to BIS with the proper documentation to receive reimbursement from a Health Care and /or Dependent Day Care Flexible Spending Account.

Limited Flex Reimbusement Form
Complete this form and submit it to BIS with the proper documentation to receive reimbursement from a Limited Flex Spending Account.

Transportation Reimbursement Form
Complete this form and submit it to BIS with the proper documentation to receive reimbursement from a Transportation Account.

Direct Deposit Form
To receive deposits via direct deposit, complete this Direct Deposit Form and submit it along with a voided check. BIS will perform a "trial send" to your account with the first processing after receiving this form, an you will receive an actual check. If the "trial send " goes without error, your next reimbursement will automatically be deposited in the account for you.

Orthodontia Treatment Form
This form will assist you in determining how much you can be reimbursed for orthodontia expenses incurred within each plan year. Please keep in mind that expenses can only be reimbursed as the service is incurred or received therefore, orthodontia expenses may be incurred but the service has not yet been received.

For more information, call our FSA Customer Service Line at 1-800-761-1934 or (952) 847-1360 or email us at flex@bis-mn.com Our Customer Service Representatives are available M - F (excluding holidays) from 8:00 a.m. to 5:00 p.m. Central Time.

Qualified Reimbursable Expenses
Links to IRS list of eligible expenses for Health Care and Dependent Day Care Flexible spending Accounts.

Follow these links to get our most requested forms. When the form appears on your screen, click PRINT on your web browser.

Health Care Expenses
Expenses incurred for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body as defined in Code 213(d) are reimbursable in a health care reimbursement account.

IRS Publication 502
http://www.irs.gov/pub/irs-pdf/p502.pdf can be used a guideline for reimbursable expenses however some expenses listed in the Publication as well as Code 213 are not reimbursable through a Health Care Reimbursement Account. If you have questions regarding a specific expenses and its eligibility, you should consult your FSA Coordinator.

Dependent Day Care Expenses
Reimbursable dependent day care expenses as defined in Code 129, and Code 21, are those employment related expenses incurred by the employee for the care of a dependent under the age of 13, or a dependent 13 or older if mentally or physically incapable of self care.

IRS Publication 503
http://www.irs.gov/pub/irs-pdf/p503.pdf can be used a guideline for reimbursable expenses however, some expenses listed in the Publication are not reimbursable through a Dependent Day Care Reimbursement Account. If you have questions regarding a specific expense and its eligibility, you should consult your FSA Coordinator.

BENEFIT INFORMATION SERVICES INC.

EMPLOYERS

EMPLOYEES

Flex Forms