Forms

Forms

You are welcome to download and print the current versions of these Manley Services forms. Just click on the links below.

All materials are in Adobe Acrobat PDF format. To open them, you must have Adobe Acrobat Reader installed on your computer. If you do not have this software, you can download it free from the Adobe Web site; click on this link and follow the instructions: Download Adobe Acrobat Reader

Authorization for Electronic Funds Transfer/Direct Deposit (to set up an account for reimbursement deposits via electronic funds transfer)	En Español
Benny™ Card Receipt Submission Form (for Benny™ card users who would prefer to submit their Benny™ Card receipts immediately, in case verification is needed, rather than wait for a receipt request letter)
Benny™ Card Refund Submission Form (for Benny™ card users who need to refund their account for ineligible charges.)
EasyPay Enrollment Form For participants who have both a Manley plan and PacificSource health insurance	En Español
Flexible Spending Account Benefit Analysis Worksheet (a guide for calculating flexible spending allottments)	En Español
Request for Reimbursement from FSA or HRA (for use with the flexible spending account or health reimbursement arrangement)	En Español
Request for Reimbursement from Transportation Benefit (for use with the transportation benefit account)
FAQ about the Grace Period (Questions and answers about the grace period for incurring expenses)	En Español
OB Guidelines (a guide for obstetric & prenatal care reimbursements)	En Español
Ortho Guidelines (a guide for orthodontia reimbursements)	En Español
Summary Plan Description (general information regarding the FSA plan)