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Diversified Benefit Services DBS
  • Services
    • back
    • Flexible Spending Accounts (FSAs)
    • Health Reimbursement Arrangements (HRAs)
    • Health Savings Accounts (HSAs)
    • COBRA Administration
    • Premium Only Plans (POPs)
    • Pre-tax Parking Plans (PPPs)
    • Member Benefit Program for American Indian Tribes (MBPs)
    • Request A Quote
  • Why DBS
    • back
    • The DBS Difference
    • DBS History
    • DBS Team
    • Testimonials
  • Participant Resources
    • back
    • Forms
    • Setting Up an Online Account
    • How to File a Claim
    • Flexible Spending Accounts (FSA) FAQs
    • Debit Card FAQs
    • Health Reimbursement Arrangements (HRA) FAQs
    • Health Savings Account (HSA) FAQs
    • Limited Purpose FSA (LPFSA) FAQS
    • Mail/Fax
    • Mobile App
    • Online
  • Broker Resources
    • back
    • Partnering With DBS
    • Request a Quote
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DBS Forms

Click and download the form you need.

  • FSA Claim Form
  • FSA Expense Worksheet/Eligible Expense List
  • HRA Claim Form
  • Direct Deposit Application
  • Letter of Medical Necessity
  • HIPAA Authorization Form

Toll Free: (800) 234-1229

Phone: (262) 367-3300

Fax: 262-367-5938

P.O. Box 260 Hartland, WI 53029

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