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FSA Claim Form

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The Deadline for Submitting Eligible Expenses to Your FSA for Plan Year 2018 is March 31, 2019!

To avoid FSA forfeiture, you must have your final Plan Year 2018 claim form postmarked (by U.S. Mail, FedEx, UPS or other paid carrier) on or before March 31, 2019. Do not use interagency mail for this filing. A​​ll items received by interagency mail on or after April 1, 2019, will be deemed as not timely filed.

If you have Adobe Professional you can fill out the form and save it as a different file for your records.

Mail the form and receipts to the address on the form or drop them off at the Employees Benefits FSA Department Offices at:

Address:  2401 N. Lincoln Blvd, RM 112, Oklahoma City, OK  73105
Main Phone:  (405) 522-1190
Fax:  (405) 522-1175

Autocalculating Flexible Spending Claim Form.

The fields will automatically calculate when values are entered in selected fields. This form meets Oklahoma 508 Accessibility Standards and is using the Employees Benefits Council Department Bar Code System for documents. This PDF revision requires Adobe Reader 8.0  to use the enhanced features correctly.​

To generate a prefilled voucher, log in to the BAS site and choose Flexible Spending / File a Claim from the menu.

If you do not receive services prior to March 15 and submit the claim prior to March 31st, money left in the plan will be forfeited.

Those links require Adobe Acrobat Reader and a browser version of 9.0 or higher. Firefox and Internet Explorer are supported, although the later is recommended for best viewing. Get a free copy Adobe Acrobat Reader.

Take you to the Adobe reader download area.

 Debit Card Purchases

Benny Card picture

Please keep all your receipts.
For example:  If you purchase over-the-counter items at places other than IRS-approved merchants*, you will need to send in receipts and a prescription to substantiate your purchases per IRS regulations.

The debit card allows employees to make health care purchases and pay for the purchase through the card program as opposed to paying cash to the provider.  This greatly increases the value of the Flexible Spending Account by providing a convenient financing tool to our employees.  An option to using the card is to pay for services and then file a paper claim for reimbursement.  The paper form of reimbursement requires you to have all your documentation before you can be reimbursed which could take several weeks depending on your insurance company.​