Forms & Documents

Current Plan Year

2021 Mid-Year Enrollment Form

Enrollment Form for participants enrolling in a 2021 FSA or DCAP

2021 FSA Enrollment Guide

Read this guide to learn about the 2021 FSA program.

2021 DCAP Enrollment Guide

Read this guide to learn about the 2021 DCAP program.

Change in Status 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) or Dependent Care Assistance Program (DCAP) election(s). Use this Form to report the change to your employer.

FSA & DCAP 2021 Claim Form

Claim form for participants in an FSA or DCAP for the 2021 plan year.

Navia Benefits Card Overview

An overview of the Navia Benefits Card for the 2021 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 a 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 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.

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.)

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.

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

Prior Plan Year

FSA & DCAP 2020 Claim Form

Claim form for participants in an FSA or DCAP for the 2020 plan year.