Make
sure your fax is legible. If your claim for
is not legible, you will not be
paid. If you can't read your copy before sending it
to us, then we definitely won't be able to read it.Forms
All forms below are in PDF format and require Adobe Acrobat Reader.
- Medical FSA Claim
Form - Request for Reimbursement
If you are looking for the medical claim form, this is it. - Daycare Request
for Reimbursement
Use this form for a single claim. - Dependent
Care Acknowledgment
Use this form at least once a year for an ongoing care arrangement. - Electronic Funds Transfer (EFT) Authorization
- Certification of Medical Necessity
- Medical Mileage Log
- Over-the-Counter Drug List
Benefit Administrator & Employer Forms
- Information Request Form
Request information from us on any of our services and plans - Feedback Form
We are always looking for ways to improve. Give us your thoughts.
If you have any questions or would like for us to send a form to you by mail, please call us toll-free at 1-800-489-1539.
FEBCO, Inc.
P.O. Box 5010
Frankfort, KY 40602
Fax
(502) 695-9692