Forms & Documents

Current Plan Year

2018 FSA Mid-Year Enrollment Form

Enrollment form for participants enrolling in a 2018 FSA or DCAP.

2018 FSA Enrollment Guide

Read this guide to learn about the 2018 FSA program.

2018 DCAP Enrollment Guide

Read this guide to learn about the 2018 DCAP program.

Navia Benefits Card Overview

Debit Card Overview for participants enrolling in an FSA.

FSA & DCAP 2018 Claim Form

Claim form for participants in an FSA or DCAP for the 2018 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.

Termination Form

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.

Change of Status Form

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.

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.

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.

Agency Transfer 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.

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

Upcoming 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.

 

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