Helpful Forms

Do you want to contribute funds to your HSA outside of payroll? If so, please complete the HSA contribution form and enclose your check or money order with the form and submit to our office. We can also process an electronic funds transfer (EFT) from your bank account to contribute the funds if you complete the CAS Direct Deposit form with your account information. 

New HSA Contribution Form

Do you need an additional card for your spouse or dependent*? Complete the additional CAS card request form and submit it to our office and you will receive your dependent's card in 7-10 business days. 

*Dependents must be at least 18 years of age.

Additional CAS Card Request Form

Medical claims have to be for dates of service that were incurred within the plan year. To process a reimbursement, the IRS requires CAS to obtain:

  • the name of the patient
  • the name of the provider or clinic where the service was provided
  • the type of service provided
  • and the amount owed or paid.

A detailed billing statement or Explanation of Benefits (EOB) from your health insurance carrier should have all the information required to process your claim.

CAS Medical Claim Form 

Do you need to submit a claim for child care expenses? Complete the CAS dependent claim form and submit to our office for processing. Don't forget, you can submit your child care claim for the entire plan year and receive your reimbursements from the account automatically as they are contributed from your payroll.

Contact our office and speak to our claims department for more information or assistance completing the form. 

All dependent care claims require the name and age of the child for which you are claiming care, the name of the provider of the service, the providers tax ID number (or Social Security Number, if an individual), and the date of service for the care. If providing a detailed billing statement, the child care provider's signature is not required. If not providing documentation, the provider must sign the form to confirm the claimed charges.

CAS Dependent Claim Form

Did you have to use your debit or credit card to make a purchase for a qualified expense?

You can receive a reimbursement from your account by logging on to your participant portal or mobile app or by submitting a claim or distribution request form to our office for processing.

​​Don't like waiting on your reimbursement check to arrive in the mail? If you prefer your reimbursements direct deposited to your checking account, complete the CAS direct deposit form with your bank's name and routing number and your account number and we will add the information to your account. Direct deposits process in 2-3 business days. You can also add the information through the CAS Participant Portal.

CAS Direct Deposit Form


Phone: 877-941-5956