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 2019 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.
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.
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.
An overview of the Navia Benefits FSA Card for the 2019 plan year.
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
Current Plan Year
Read this guide to learn about the 2020 FSA program.
Read this guide to learn about the 2020 DCAP program.
Limited OE Change in Status Form
During the Limited OE period July 1-31, 2020 employees may enroll or change their Medical Flexible Spending Arrangement (FSA) or Dependent Care Assistance Program (DCAP) election(s) without a special open enrollment (SOE) event. Use this Form to report the change to your employer.
Enrollment Form for participants enrolling in a 2020 FSA or DCAP
Claim form for participants in an FSA or DCAP for the 2020 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.
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.
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 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.
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.)