Please note: There is a grace period to December 31, 2022 for you to incur eligible expenses and spend down any remaining funds in your 2021 Health Care FSA and or your 2021 Dependent Care FSA.

You may only receive reimbursements for services incurred during periods when you made contributions to your FSA. When contributions end, the PayFlex debit card is inactivated and your account is expired.

Flexible Spending Account Forms

Enrollment Form

• 2022 Health Care FSA and or Dependent Care FSA Enrollment Form - For new employees or newly eligible for benefits, for accounts begin on or after January 1, 2022

The fund availability dates apply to health care claims. To receive reimbursement for dependent daycare expenses, you must have enough money in your Dependent Care FSA to cover the claim being made.

Change in Status Request Forms

• Changes in deduction amounts will be effective the first day of the month following the receipt of the form. 
• Please note that decreases cannot be less than amounts for which you have already received reimbursement from the plan.
• Unfortunately, the IRS does not permit a refund of pre-tax dollars that are contributed to an FSA.

To change your FSA contributions, complete and return a Request for Change in Status form:

• Health Care FSA Request for Change in Status
• Dependent Care FSA Request for Change in Status

Other Forms

• Dependent Care Provider's Identification and Certification
• PayFlex Health Care and Dependent Care FSA Claim Form

Flexible Spending Account Book

• 2022 Flexible Spending Accounts -  effective January 1 - December 31, 2022. Unlike other benefits, IRS rules do not allow FSA enrollments to carry over from year to year. You need to enroll in an FSA each year you wish to participate. Sign up during annual Open Enrollment.

More Information on Flexible Spending Accounts

• What is an FSA?
• PayFlex Flexible Spending Account - A quick summary of health care and dependent care flexible spending accounts, administered by PayFlex.
• PayFlex FSA Card - A guide to using the PayFlex Card, your FSA debit card
• Stay Connected to Your PayFlex Account - Information on managing your account online, signing up for account notifications, and using the PayFlex Mobile® app.
• Learn how to use an FSA to pay for dental expenses
• PayFlex Claim Filing Guidelines