Forms & Documents
The following forms and documents are available for you to download in PDF format.
Prior Plan Year
Claim form for participants in an FSA or DCAP for the 2021 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 our website.
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
Current Plan Year
2022 Mid-Year Enrollment Form
Enrollment Form for participants enrolling in a 2022 Medical FSA, Limited Purpose FSA, or DCAP.
Medical FSA, Limited Purpose FSA, and DCAP 2022 Claim Form Claim form for the 2022 plan year.
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 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 experience a qualified special open enrollment (SOE) event, you may be eligible to enroll or change your Medical Flexible Spending Arrangement (FSA), Limited Purpose FSA, or Dependent Care Assistance Program (DCAP) election(s). Use this Form to report the change to your employer.
Read these documents to learn about the 2022 FSA program.
Read these documents to learn about the 2022 DCAP program.
2022 Limited Purpose FSA Enrollment Guide
2022 Limited Purpose FSA Overview
2022 Limited Purpose FSA Eligible Expenses
Read these documents to learn about the *NEW* 2022 Limited Purpose FSA program.
An overview of the Navia Benefits Card.
Direct Deposit and Debit Card Form
If you would like to enroll in direct deposit for your FSA or DCAP reimbursements, or to request a debit card, please complete this form and return it to Navia Benefit Solutions. Alternatively, you can request these changes online by logging into your Navia member portal.
If you enroll in the Medical Flexible Spending Arrangement (FSA), Limited Purpose FSA, and/or Dependent Care Assistance Program (DCAP) and later change jobs to work at another Washington State agency, higher-education institution, or community and technical college, your enrollment may continue if your new position is eligible for participation in the Public Employees Benefits Board (PEBB) Program FSA and DCAP. Use this Form to process the transfer.
If you end employment during the plan year or you retire, complete and sign this form, then return it to your employer’s personnel, payroll, or benefits office within 30 calendar days of your PEBB benefit end date.