Claim Form with Instructions – Medical FSA and Dependent Care
Please submit your claims with receipts by either fax (925.460.3929) or via mail (EBS, P.O. Box 11657, Pleasanton, CA 94588). Should you have any questions on how to file your claim, instructions follow the claim form in the above link. You may also call our Customer Service Center for assistance from 8AM – 5 PM PST, Monday through Friday at 888.327.2770.

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Dependent Care Bill from Provider Form
This form is for those participating in the Dependent Care plan. This form can be used in lieu of multiple receipts from your dependent care provider. For example, you can fill out the form for any amount of time up to the end of the plan year, have your provider sign the form (agreeing to the information you have completed), complete and attach to a claim form and fax or mail it to EBS. If you use this form, you will not need to send in weekly, monthly or quarterly receipts.

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Eligible Expenses – Medical FSA and Dependent Care

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Direct Deposit Initiate / Change / Delete Form
This form can be used to initiate, change or cancel your direct deposit. This service alleviates the time spent waiting for a check in the mail and is available to all plan participants. Please allow two weeks after receipt by EBS for your direct deposit to be set-up for reimbursement.

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Frequently Asked Questions

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FSA Savings Calculator

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Instructions for Creating / Accessing your Account

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Create / Access your Online Account

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Information Release Document


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PO Box 11657
Pleasanton, CA 94588
Employees / Members 888.327.2770
Employers/ Brokers 800.229.7683