FY17 Flexible Spending Account Enrollment Form pdf format of FSAenrollmentform.pdf
–  Use this form if you are enrolling for the first time as a new hire.

Current Participants Re-enroll online during Open Enrollment – If you are a current FSA participant, re-enroll online during the April 5 – May 3, 2017 open enrollment period for coverage effective July 1, 2017.  Refer to the attached re-enrollment instructions docx format of online_FSA_reenrollment_instructions.docx

Flexible Spending Account Status Change Form  docx format of Flexible Spending Account Status Change Form
– use this form to increase or decrease your contribution to, or terminate your election in Flexible Spending Account within 60 days of a qualifying event during the plan year. You must submit this form with supporting documentation within 60 days of the qualifying event: change in legal marital status; change in number of dependents; change in employment status; change in work schedule that affects your eligibility for the program; change in dependent’s FSA eligibility, a judgment decree pertaining to your spouse or child, change in cost of care and/or change of provider.

DCAP Claim Form doc format of GIC_FSA_claimform2015.doc
: Use this form to submit dependent care-related claims for reimbursement.

Flexible Spending Account Appeal Form docx format of FSA_Appeal_Form.docx
- If you disagree with a denied claim or adverse decision regarding your HCSA or DCAP benefit (e.g. claim for reimbursement denial, eligibility for pre-tax benefits or election change), and you feel this denial was made in error you may file a formal appeal by using this form.

HCSA Questions?

2017 Flexible Spending Account Handbook  pdf format of FSA_handbook_FY17.pdf
Contact ASIFlex; 1-800-659-3035

This information provided by the Group Insurance Commission .