ASIFlex - Forms

ISU FSA Forms and Documents

Form Type/Document	File Type	Description
FSA/DCAP Claim Form		Submit this form in order to request reimbursement for your out-of-pocket expenses. Please note that you will need to include a detailed service statement (NOT JUST PROOF OF PAYMENT) in order for your reimbursement request to be approved.
Claims Rollover Authorization Form		If you would like to have ASIFlex receive claims data from Wellmark, Medco and/or Delta Dental and issue automatic reimbursements to you for your deductible, co-insurance and co-payment expenses, please complete this form. You can also stop your auto reimbursement arrangement by completing this form.
Direct Deposit/Email Notification Sign up		If you would like to expedite your reimbursement and notification process from ASIFlex, please complete this form. This information will be maintained in ASIFlex's system for as long as you are enrolled in the programs.
HIPAA Release of Information Form		If you would like to have another individual be able to call ASIFlex and access detailed information about your account, please complete this form.
Letter of Medical Necessity		Certain medical expenses require that this form be completed by your medical provider in order for them to be eligible for reimbursement.
Flexible Spending Account Enrollment Guide		Review the detailed information governing use of your ISU Flexible Spending Account.