Employees can also receive copies of these forms through their Payroll Coordinator.

HCSA Enrollment Form for 2012  : Eligible employees may enroll in 2012 HCSA calendar year benefits with a qualifying event during the 2012 year, complete and return the attached form to your payroll coordinator.

HCSA Claim Form  - use this form to submit 2011 HCSA and DCAP claims for reimbursement.

HCSA Termination Form  - HCSA enrollees who leave state service or take a leave of absence, must terminate their HCSA participation using this form.

HCSA COBRA 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.

HCSA Questions?

Benefit Strategies 1-877-FLEXGIC (1-877-353-9442); flexgic@benstrat.com
 

HCSA/DCAP Participant Handbook FY2012 

 

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This information provided by the Group Insurance Commission.