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Print Form Clear Form Fax to ASIFlex 877 879-9038 No Cover Page Required STATE OF OREGON FSA CLAIM FORM Documentation Requirements Instructions See back side Page 1 of P Last Name First Name MI Please Print PEBB-assigned ID P 8 digit ID Street Address City State Zip Dependent Care Flexible Spending Account day care babysitting etc. Dependent care expenses must be for a dependent who is incapable of self care or under the age of 13 at the time th.

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Unfortunately, FSA cards cannot be used to withdraw FSA funds from an ATM. These cards can only be used directly on qualifying medical products and services. This comes from the fact that FSA funds are pre-tax and cash cannot be easily monitored for eligible purchases.

Facts about Flexible Spending Accounts (FSA) You can spend FSA funds to pay deductibles and copayments, but not for insurance premiums. You can spend FSA funds on prescription medications, as well as over-the-counter medicines with a doctor's prescription. Reimbursements for are allowed without a prescription.

Covered services include bridges, cleanings, crowns, dental implants, dentures, extractions, fillings, orthodontia, periodontal services, sealants and x-rays.

The debit card lets you electronically access pretax contributions you set aside in your flexible spending accounts (FSAs). How does the debit card work? It works like a MasterCard®, with the value of your account(s) contributions stored on it.

You can always call ASIFlex directly at 1-800-659-3035 with any questions that you have.

Covered Expenses Include: Medical and dental deductibles and co-payments. Many over-the-counter (OTC) medicines (see the OTC Guide for more information) Eye Exams, contact lenses, and glasses. Physical therapy. Chiropractic care. Hearing aids. Smoking cessation items(may require a prescription)

What is the mileage reimbursement rate? The standard mileage rate for use of an automobile to obtain health care during the following time periods is as follows: 22 cents per mile = Jul 1 – Dec 31, 2023. 22 cents per mile = Jul 1 – Dec 31, 2022.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232