Health Care Spending Account (HCSA) Forms

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

HCSA Enrollment Form for 2013  : New Employees can enroll as a new hire. Eligible employees, can enroll or during the 2013 year with a qualifying event. Return the completed form to your payroll coordinator.

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

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 FY2013    

This information provided by the Group Insurance Commission.