Forms & DocumentsThe following forms and documents are available for you to download in PDF format.
Current Plan Year Forms
2025 Midyear Enrollment Form: Enrollment Form for newly eligible participants enrolling in a 2025 FSA, Limited Purpose FSA, or DCAP.
FSA, Limited Purpose FSA, and DCAP 2025 Claim Form: Claim form for the 2025 plan year.
DCAP Recurring Claim Form: If you want your monthly day care claim to be automatically filed each month, please complete this form.
Orthodontia Contract: Use this form to set up your monthly orthodontia payments as a recurring FSA claim.
Letter of Medical Necessity: 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.
HIPAA Release Form: 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.
Change in Status Form: If you experience a qualified special open enrollment (SOE) event, you may be eligible to enroll or change your 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.
Agency Transfer Form: If you enroll in a Flexible Spending Arrangement (FSA) and/or Dependent Care Assistance Program (DCAP) and later change jobs to work at another Washington State agency or higher education institution, your enrollment may continue if your new position is eligible for participation in the PEBB Program FSA and DCAP. Use this Form to process the transfer.
FSA Termination Form: 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.
Current Plan Year Documents
Read these documents to learn about the 2025 FSA program.
Read these documents to learn about the 2025 DCAP program.
Read these documents to learn about the 2025 Limited Purpose FSA program.
2025 Limited Purpose FSA Enrollment Guide
2025 Limited Purpose FSA Eligible Expenses
Navia Benefits Card Overview: An overview of the Navia Benefits Card.
Watch Navia’s recorded PEBB FSA & DCAP Education Session to learn more about 2025 enrollment.
HCA’s privacy notice: The Health Care Authority (HCA) will keep your information private as allowed by law. See our Privacy Notice.
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Questions
Contact us at (800) 669-3539, Monday – Friday from 5:00am to 5:00pm PST