Browse a list of FSA, HSA, HRA eligible expenses. Use your TASC Card to pay for healthcare-qualified expenses at clinics, optometrists, dentists, pharmacies and other merchants.

certify the total cost of qualified adult/child care services below have been provided during the period indicated for the dependents on this form. To the best of my knowledge and belief, all statements and information provided with this Request for Reimbursement are complete and true.

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personal statement on demand, submit claims online, and print all of the forms necessary to manage your accounts.

FlexSystem Participants now have two easy ways to submit requests for reimbursement along with substantiation in one simple action: the online Request for Reimbursement form in MyTASC and the MyTASC Mobile App (for Apple, Android, and Kindle devices). Either way, it takes only a minute to submit a complete claim from start to finish.

For quick reimbursement, file online via your employee portal (partners.tasconline.com/tasclppt) or Mobile App! Submit your claim form with supporting documentation via fax to 877-231-1287. To the best of my knowledge and belief, my statements on this Request for Reimbursement are complete and true.

From what initial date would you like reimbursements of your premium(s) to start? This is required information and must be filled out completely to process your request. Please initial next to each line to indicate you acknowledge the terms of this recurring premium reimbursement request.

Important: A new form must be submitted each year when your policy rate changes*, (beginning of new plan year or policy end date) to update your recurring reimbursements with your new rate. Refer to Additional Instructions on page 2.

TASC Client Packet | 3a Authorization – Individual | Version 10.05.18 Authorization I, _____ [insert client’s name here], whose birthdate is ____/____/____ [insert DOB] authorize TASC, Inc. to communicate with and receive from: List one individual/organization name and address: 1.

Use this form to be reimbursed for healthcare products and services that require authorization from a Medical Practitioner to be considered eligible for reimbursement from a Flexible Spending Account (FSA), Health Reimbursement Arrangement (HRA) or other TASC benefit account. Complete the form on the following page.