Flexible Spending Account Enrollment Form
- Health Care FSA and/or Dependent Care FSA Enrollment eForm (a paper form is available here)
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 eForm (a paper version of the form is available here)
- Dependent Care FSA Request for Change in Status eForm (a paper version of the form is available here)
- Dependent Care Provider's Identification and Certification
- PayFlex Health Care and Dependent Care FSA Claim Form
Flexible Spending Account Books
- 2023 Flexible Spending Accounts (effective January 1 - December 31, 2023)
- 2024 Flexible Spending Accounts (effective January 1 - December 31, 2024)
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