Not for municipalities

FSA Worksheet docx format of FSAworksheetspring2016.docx
– use this worksheet to help calculate your election amount.

FY17 Flexible Spending Enrollment Form pdf format of FSAenrollmentform.pdf
–  Use the form to enroll for the first time as new hire.

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, or a judgment decree pertaining to your spouse or child.

HCSA Claim Form doc format of GIC_FSA_claimform2015.doc
- use this form to submit HCSA and DCAP 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?

Contact ASIFlex; 1-800-659-3035

2017 Flexible Spending Account Handbook  pdf format of FSA_handbook_FY17.pdf


This information provided by the Group Insurance Commission .