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Health Care Spending Account (HCSA) forms

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

Complete the forms

Benefit Strategies - benefits effective July 1, 2019

All forms can be found online at Benefit Strategies website.

ASIFlex - benefits effective until June 30, 2019

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

Flexible Spending Account 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.

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

HCSA and DCAP 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

ASIFlex handbook

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