Western Maryland Health System

Flexible Spending Accounts

Listed below are forms to help you with Flexible Spending Accounts (click on the form name to open and print).

Form	Purpose
Meritain Flexible Spending Account Direct Deposit Form - (PDF File)	A printable form to be used when electing to have your FSA reimbursement deposited to your savings or checking account. Must be faxed or mailed with your reimbursement request to Meritain. (Address/fax number on the form)
Meritain Flexible Spending Account Claim Form - (PDF File)	A printable form required when submitting your request for reimbursement of your FSA claims. Must be faxed or mailed to Meritain. (Address/fax number on the form)
2010 FSA Eligible Expenses Form - (PDF File)	Printable form for your use. the IRS establishes the guidelines for reimbursement expenses and a partial list is provided. For additional verification, please visit www.irs.gov and view Publication 502 for a complete listing.
2011 FSA Eligible Expenses Form - (PDF File)	Printable form for your use. the IRS establishes the guidelines for reimbursement expenses and a partial list is provided. For additional verification, please visit www.irs.gov and view Publication 502 for a complete listing.
FSA Summary Plan Description - (PDF File)	Printable copy of the flexible spending account summary plan description.

If you have any questions regarding this benefit, please call Human Resources at 240-964-8157 or 48159 or email June Ward, Benefits Coordinator at jward@wmhs.com or Jill Rowley, Benefits Assistant at jrowley@wmhs.com or call 240-964-8159.