Flexible Spending Account Forms

2020 Enrollments: The Internal Revenue Service regulates Flexible Spending Accounts (FSAs). Unlike other benefits, IRS rules do not allow FSA enrollments to continue from one year to the next.

• Open Enrollment Participants:  If you are currently enrolled in an FSA and want to participate in 2020, you will need to re-enroll. Download the 2020 Health Care FSA and or Dependent Care FSA Enrollment Form. Submit your completed and signed form by December 6, 2019. Learn more.

• New Employees or Newly Eligible for Benefits: If you are a new employee or newly eligible for benefits and your job is on the U-M system after 5:00 p.m. on October 11, 2019, your enrollment for most benefits will continue through December 31, 2020 as long as you remain eligible. However, if you want to participate in an FSA you will need to complete and submit separate forms to participate in 2019 and/or 2020.

• 2019 Health Care FSA and or Dependent Care FSA Enrollment Form for new employees.
• 2020 Health Care FSA and or Dependent Care FSA Enrollment Form for new employees only.
• Health Care FSA Request for Change in Status
• Dependent Care FSA Request for Change in Status
• Dependent Care Provider's Identification and Certification
• PayFlex Health Care and Dependent Care FSA Claim Form

Flexible Spending Account Book

• 2019 Flexible Spending Account Book 
• 2020 Flexible Spending Account Book (for FSAs with an effective date on or after January 1, 2020)

More Information on Flexible Spending Accounts

• 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