Flexible Spending Account Forms and Documents

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

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:

Other Forms

Flexible Spending Account Book

More Information on Flexible Spending Accounts