Please note: 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

Please note: The maximum age for eligible dependent children covered under the Dependent Care FSA has changed from 12 to 13.

• 2021 Health Care FSA and or Dependent Care FSA Enrollment Form

Change in Status Request Forms

In December 2020, the IRS issued revised rules for FSAs under the Consolidated Appropriations Act. This notice provides increased flexibility for 2021 Health Care FSA and Dependent Care FSA participants to make midyear changes during the 2021 calendar year.

• You may only increase or decrease your 2021 annual election once during the plan year without a corresponding change in status event.
• Changes in deduction amounts will be effective the first day of the month following the receipt of the form. The final deadline for submitting changes to your 2021 FSA deduction amounts is November 2021 with the change effective for December 2021 paychecks.
• 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

• 2021 Flexible Spending Accounts - updated March 31, 2021 to include face masks, hand sanitizer and sanitizing wipes as qualified medical expenses if used for the primary purpose of preventing the spread of the COVID-19 coronavirus per IRS Announcement 2021-7.

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