Independent Health Flexible Spending Account (FSA) Claim for UB Foundation (UBF)

Make a general claim for expense reimbursement on your Independent Health Flexible Spending Account. This is for use with the UB Foundation.

Mobile Users

For the best experience in completing this form use a non-mobile device.

Using Firefox with PDF forms?

Make Adobe Acrobat the reader.

Completing the PDF Form

  1. Read through all pages of the document to find specific instructions
  2. Enter requested information into the form
  3. Print the form
  4. Get required signatures
  5. Scan a copy of the signed form for your records
  6. Send the original, completed, signed form to:

Independent Health Corporation
Attn: FSA Administration
511 Farber Lakes Drive
Buffalo, NY 14221 

Need help completing the form?

Send email, phone or submit a question

Joyce Weeman

Joyce Weeman

Benefits Specialist

UB Foundation

Phone: 716-645-8731


UB Foundation


UB Foundation

Phone: 716-645-3013


(We'd like to respond to you.)

Form Facts

Form Type: Downloadable, PDF document

Requirements: Adobe Reader

Updated: June 7, 2011

Owner: UB Foundation