FSA Worksheet – use this worksheet to help calculate your election amount.
Open Enrollment Re-enrollment Instructions – If you are a current FSA participant, re-enroll for fiscal year 2017 benefits online during the Open Enrollment period.
FY17 Flexible Spending Enrollment Form – Enrolling for the first time during Open Enrollment or are 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.
Flexible Spending Account Appeal Form - 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.
Contact ASIFlex; 1-800-659-3035
This information provided by the Group Insurance Commission .