Claim Form

  Use this form to file a manual reimbursement request.

 Dependent Care Acknowledgement Form

   Use the Dependent Care Acknowledgement Form, to claim your annual DCA account amount.

 Direct Deposit Form

  Use this form to set up your Direct Deposit.

 Medical Mileage Form

  Attach this form to your claim form to be reimbursed for Medical Mileage.

 Additional Febco Card Request Form

  Use this form to request any additional Febco Benefits MasterCards for your spouse and/or dependents.

 Change of Address Form

  Use this form to change your email, telephone number, and/or mailing address.

 Proof of Insurance Form

  Use this form to provide Febco with proof of insurance. (This is not a reimbursement request, only proof.)

 Medical Necessity Certification Form

  According to the IRS rules and regulations, some medical products and services are only eligible to be reimbursed when your doctor or health care provider deems them medically necessary.

 E.O.B. Verification Form

 Use this form to provide Febco with proof that Deductible has been met. (This is not a reimbursement request)