Health Care Spending Account (HCSA) Forms

Find out information on how to enroll, change, or appeal your Health Care Spending Account

FSA Worksheet – Use this worksheet to help calculate your election amount.

Current Participants Re-enroll online during Open Enrollment – If you are a current FSA participant, re-enroll online during the April 5 – May 3, 2017 open enrollment period for coverage effective July 1, 2017.  Refer to the attached re-enrollment instructions.

FY18 Flexible Spending Account Enrollment Form – use this form to enroll in FSA benefits as a new participant during the spring GIC open enrollment period.  This form is also for enrolling for the first time 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 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 - 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.

HCSA Questions?

Contact ASIFlex; 1-800-659-3035

FY18 Flexible Spending Account handbook 


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