Frequently Used Forms

Please allow 4-12 business days for all form submissions to be processed.

Use this form to submit a reimbursement to the Difference Card.
Use this form to submit your FSA, DCA, and transit/parking reimbursement to the Difference Card.
Difference Card must obtain authorization before using or disclosing protected health information (PHI). Download
This letter is used to assist you and your health care provider in providing the information needed to process a claim. Download
Use this worksheet to help determine your annual healthcare contributions for the upcoming plan year. Download
View a complete list of thousands of products that are FSA eligible and can be purchased through your Difference Card. View List
Download and complete this form to earn points for your Annual Physical Exam. Download
Download and complete this form to earn points for regular physical activity. Once completed, submit it to the Difference Card. Download
If you attended a Live Wellness Webinar, complete this form and send it to the Difference Card to receive your wellness points. Download


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The Difference Card®
245 Main Street | Suite 605
White Plains, NY 10601
(888) 343-2110
(914) 220-0901
info@differencecard.com

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