Flexible Spending Account Book
- For detailed information on FSAs, view the 2015 Flexible Spending Accounts Book
- 2016 Flexible Spending Account Book for accounts effective on or after January 1, 2016
Flexible Spending Account Forms
Looking to enroll in an FSA for 2016? Download and complete the 2016 Flexible Spending Account Deduction Authorization Form. Submit your signed and completed form by:
- December 4, 2015 to have your FSA available for reimbursement beginning on January 1, 2016
- December 31, 2015 to have your FSA available for reimbursement beginning on February 1, 2016. You may incur eligible expenses in January, but you may not use your PayFlex/HealthHub card to pay for health care expenses and your account will not be set up and ready for you to submit claims until February 1, 2016.
Please note: The enrollment deadlines and reimbursement availability dates refer to Heath Care FSAs only. For reimbursement from a Dependent Care FSA, you must have the full amount of your claim deposited in your Dependent Care FSA in order to receive reimbursement for the claim.
The following enrollment forms are for new employees or newly eligible faculty and staff. Enroll within your 30-day deadline or as specified by your collective bargaining agreement.
- 2015 Health Care FSA and/or Dependent Care FSA Enrollment Form
- 2016 Health Care FSA and/or Dependent Care FSA Enrollment Form
- Health Care FSA Request for Change in Status
- Dependent Care FSA Request for Change in Status
- Dependent Care Provider's Identification and Certification