Forms & Documents

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

Current Plan Year

2019 FSA Enrollment Guide

Read this guide to learn about the 2019 FSA program.

2019 DCAP Enrollment Guide

Read this guide to learn about the 2019 DCAP program.

2019 Mid-Year Enrollment Form

Enrollment form for participants enrolling in a 2019 FSA or DCAP.

FSA & DCAP 2019 Claim Form

Claim form for participants in an FSA or DCAP for the 2019 plan year.

Navia Benefits Card Overview

An overview of the Navia Benefits FSA Card for the 2019 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.

Direct Deposit and Debit Card Form

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.

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 Public Employee Benefits Board (PEBB) benefit end date. (Exception: University of Washington employees must make changes online in Workday.)

Change in Status Form

Employees may enroll or revoke their Medical Flexible Spending Arrangement (FSA) or Dependent Care Assistance Program (DCAP) election(s) and make a new election when a special open enrollment (SOE) event occurs. Use this Form to report the SOE to your employer.

Agency Transfer Form

If you enroll in the Medical Flexible Spending Arrangement (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 Medical FSA and DCAP. Use this Form to process the transfer.

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.

Educational video: Watch a presentation about the FSA and DCAP programs

 

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