Forms & Documents

The following forms and documents are available for you to download in PDF format.

Current Plan Year

 

Enrollment form for participants enrolling in a 2016 FSA or DCAP.

Read this guide to learn about the 2016 FSA program.

Read this guide to learn about the 2016 DCAP program.

Debit Card Overview for participants enrolling in an FSA.

Claim form for participants in an FSA or DCAP for the 2016 plan year.

Read this guide to learn how to submit a recurring day claim through your online profile.

If you want your monthly day care claim to be automatically filed each month, please complete this form.

Use this form to set up your monthly orthodontia payments as a recurring FSA claim.

Certain expenses require a provider’s authorization in order for them to be eligible for reimbursement. Complete this form for expenses that require a provider’s authorization.

If you cease employment during the plan year, please review and complete this form. Return the completed form to your personnel, payroll, or benefits office for processing.

If you have experienced a qualifying event and would like to make a corresponding change in your annual election, complete this form and return it to your personnel, payroll, or benefits representative.

If you would like to enroll in direct deposit for your FSA or DCAP reimbursements, or to request an FSA debit card, please complete this form and return it to Navia Benefit Solutions.

If you would like to have another individual be able to call Navia Benefit Solutions to discuss your benefits and detailed information about your account, please complete this form.

If you have terminated employment with an agency and been rehired within 30 days with a new agency, complete this form to continue your FSA or DCAP benefits.

 

Previous Plan Year

 

Claim form for participants in an FSA or DCAP for the 2015 plan year.

 

HCA’s Privacy Notice: The Health Care Authority (HCA) will keep your information private as allowed by law. To see our Privacy Notice, go to www.hca.wa.gov/pebb.

Please make sure to download the latest version of Adobe Reader prior to opening the PDF documents above.

Questions?
Contact us at (800) 669-3539, Monday – Friday from 5:00am to 5:00pm PST