• Online Forms
• Request a Hard Copy

Online Forms

The following documents are provided in Adobe PDF format.

1. Select the appropriate form below.
   
   
   • Flexible Spending Account Over-the-Counter Health Care Reimbursement Form (GC-15)
     (PDF: 220 KB / 2 pages)
   • Flexible Spending Account Health Care Reimbursement Form (GC-11)
     (PDF: 318 KB / 2 pages)
   
   
   
   • Flexible Spending Account Dependent Care Reimbursement Form (GC-12)
     (PDF: 320 KB / 2 pages)
   
   
   
   • Flexible Spending Account Claim Submission Guidelines (GC-1446)
     (PDF: 26 KB / 2 pages)
   
   
   Viewing: For easier viewing, click on the Acrobat Reader's Zoom button and then click down anywhere on the page.
   
   
2. Fill-In Form: To fill the form in online, use the "Tab" key to move through the fields or click on a field using the mouse. Note: The tab key does not stop at check box fields. You must click each check box field using the mouse. Once the form is complete, print using the printer icon from the Acrobat toolbar.
   
   The Acrobat Reader will not allow you to save your completed forms to disk. The "Save As" command on the Acrobat toolbar will only save the form as an unfilled form. Therefore, the only options are to print or email the filled form once it is complete.
   
   OR
   
   Print: Print the form and complete it manually. Note: To print the form, you must use the print icon from the Acrobat Reader toolbar.
   
   
3. Submit Form: Send the completed Benefit Request Form and appropriate documentation to the Aetna Service Center that services your employer. This information can be obtained from the claim form.

• Request a hard copy through the Aetna Service Center that services your employer.