2015 HCSA Enrollment form for new participants - Enroll in HCSA benefits for 2015 as a new hire.
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 30 days of a qualifying event during the plan year. You must submit this form with supporting documentation within 30 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, or a judgment decree pertaining to your spouse or child.
HCSA Claim Form - use this form to submit HCSA and DCAP claims for reimbursement.
2015 HSCA Notice and Election Form - HCSA Enrollees may elect to contribute to the HCSA account under COBRA by making direct payments on an after-tax basis.
HCSA COBRA Acknowledgement Form - State employees enrolled in HCSA who are leaving state service use this form to acknowledge that they have been advised of their right to HCSA COBRA benefits.
Open Enrollment Re-enrollment Instructions (not yet available) 2015 participants will re-enroll for 2016; these instructions will explain the online re-enrollment steps.
Contact ASIFlex; 1-800-659-3035
This information provided by the Group Insurance Commission .
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