Claims & Enrollment Forms The forms below require Adobe Acrobat Reader to view. Please click here to download. HRA Manual Claim Form QTA Manual Claim Form (Word Version) QTA Manual Claim Form (Fillable) FSA/DCA Manual Claim Form (Fillable) FSA/DCA Manual Claim Form (Word Version) FSA Medical Necessity Form FSA Capital Expenditure Form FSA Eligible & Ineligible Expenses FSA/DCA/QTA Enrollment Form (Fillable) FSA/DCA Enrollment Form (Spanish) (Fillable) HRA Enrollment/Change Form PBS On-Line Sign-on Instructions FSA Store Eligibility List
