NYS Flex Spending Account 2017 Forms

SPECIAL NOTE

If you need a form for the 2016 plan year, please choose from the 2016 plan year forms list instead of the list below.



Submit Your Claims Online

You can now submit your reimbursement requests online through myFBMC.com. This process allows you to submit, via FBMCs secure website, a scanned image of your completed claim form along with scans of your supporting documentation.

First time users should follow the instructions to complete the New Users registration process. After you have registered at myFBMC.com, logon, click on the Claims tab, then select "Online FSA Claim Submission" from the drop down box.



Health Care Spending Account Forms

Online HCSAccount Change In Status Application
HCSAccount SAMPLE Reimbursement Form
HCSAccount Reimbursement Request Form and Instructions (PDF VERSION) (FILL-IN FORM VERSION)
Letter Of Medical Need Form
Personal Use Items/Special Foods Form
Capital Expenditure Worksheet

Dependent Care Advantage Account Forms

Online DCAAccount Change In Status Application
DCAAccount SAMPLE Reimbursement Form
DCAAccount Reimbursement Request Form (PDF VERSION) (FILL-IN FORM VERSION)
DCAAccount Reimbursement Request Form Instructions (PDF VERSION)

Other Forms

Enter The RACE (Direct Deposit) Form (PDF VERSION)


Forms  
 
Andrew M. Cuomo, Governor