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Category: Flex and Health Savings Account Forms

Flexible Spending Account (FSA) Claim Form

Complete this form to submit eligible expenses for reimbursement from your Flexible Spending Account (FSA).  This form and any receipts or documentation must be sent directly to PEHP by mail to the address listed on the form or via fax to 801-366-7772 Flex Claim Form

Flexible Spending Account (FSA) Enrollment Form

Complete this form to enroll in a Flexible Reimbursement Account. Flex Enrollment Form OR Online Flex Enrollment (Once logged in to your myPEHP account, select Online Enrollment)

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