You can view the forms listed below (in .pdf format) using Adobe Acrobat Reader, which is free and easily accessible. These documents are best viewed using Acrobat Reader version 7.0 or higher. If you use a lower version of Adobe Acrobat Reader, you may receive a message indicating the form was created using a more recent version of Adobe, but that should not affect your ability to view the form. Select Adobe Acrobat Reader 7.0 to download a free version of the Reader.

All FSAFEDS forms are 508-accessible.

Claim Forms: Health Care Claim Form - To submit health care expenses for reimbursement. (Note: To save to your desktop, right click on the above link and select Save As. You can now name the file and save to your computer.) All claims and supporting documentation must be submitted in English. Dependent Care Claim Form - To submit day care expenses for reimbursement. (Note: To save to your desktop, right click on the above link and select Save As. You can now name the file and save to your computer.) All claims and supporting documentation must be submitted in English. Other Forms Dependent Care Tax Credit Worksheet - Assists DCFSA participants in determining the best option between the Federal Child Care Tax credit and a Dependent Care Flexible Spending Account. Capital Expense Worksheet - Helps to determine if your expense is eligible. Belated Enrollment Form - Allows enrollment outside Open Season for reasons outside your control EFT Form - Captures Electronic Funds Transfer (EFT) information for direct deposit of FSA reimbursement Letter of Medical Necessity Form - Provides a convenient way for your physician to provide medical necessity information for dual purpose expenses Qualifying Life Events Form - allows you to change your election when certain events occur (For more information, see Qualifying Life Events Fact Sheet.) Back to top

FSAFEDS Quick Reference Guides

• Appeal Process - Learn how the appeals process works regarding denied claims



• Clean Claim - Learn how to successfully complete an FSAFEDS claim form



• Leave Without Pay (LWOP) - Learn about eligibility regarding a LWOP event



• Orthodontia - Learn how to claim reimbursement for orthodontia expenses



• Over-the-Counter (OTC) - Learn which OTC expenses are eligible for reimbursement



• Paperless Reimbursement Overview - Learn about plans participating in the paperless reimbursement program



• Qualifying Life Event (QLE) - Learn about eligibility regarding a QLE event

Supplemental Information

• The Federal Flexible Benefits Plan (FedFlex) - The official plan document that governs FSAFEDS.
  
  This is a legal document conforming to IRS regulations and, by design, not meant as a quick reference. The Internal Revenue Service requires all flexible spending account programs to have a plan document available to all enrollees. The Summary of Benefits with Frequently Asked Questions is the plain English version of the FSAFEDS portions of the plan document.



• Eligible Expenses - A detailed listing of eligible and ineligible expenses



• Summary of Benefits with Frequently Asked Questions - The plain language version of the plan document with answers to the most common questions about the Health Care and Dependent Care Flexible Spending Accounts



• IRS Publication 502 - Note: While insurance premiums are included in Publication 502, they are NOT reimbursable expenses for FSA purposes.



• Payroll Schedules - A list of timing schedules for payroll processing



• Program Overview - A quick reference about FSAFEDS