Get the free HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM
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This form is used by employees to enroll in or make changes to their Health Care and Dependent Care Flexible Spending Accounts.
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How to fill out HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM
01
Obtain the HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM from your HR department or company intranet.
02
Read the instructions carefully to understand the options available.
03
Fill out your personal information at the top of the form, including your name, address, and employee ID.
04
Choose between health care and dependent care flexible spending accounts, if applicable.
05
Indicate the amount you wish to contribute to each FSA per pay period.
06
Provide any necessary information regarding any dependents you wish to cover under the dependent care FSA.
07
Sign and date the form to certify the information provided is accurate.
08
Submit the completed form to your HR department by the deadline specified in the instructions.
Who needs HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM?
01
Employees who wish to set aside pre-tax dollars for qualified medical expenses.
02
Employees who need assistance in covering dependent care expenses while they work.
03
Employees changing their contribution amounts due to qualifying life events or plan year changes.
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People Also Ask about
What does FSA mean?
A Flexible Spending Account (FSA, also called a “flexible spending arrangement”) is a special account you put money into that you use to pay for certain out-of-pocket health care costs.
How do I submit a claim to FSA?
Log in to the FSAFEDS app using the same username and password as your online account. Select whether to submit a claim or pay a provider. Follow the prompts to enter claims details. Take photos of your itemized receipts (and other documentation if needed) or upload from your mobile device.
What is the health care flexible spending account NYC?
About HCFSA. The Health Care Flexible Spending Account (HCFSA) Program allows City employees to pay for eligible out-of-pocket health care expenses on a pre-tax basis, with deductions taken directly from salary.
What is an FSA document?
What are FSAs? A flexible spending account, or FSA, is an employer-sponsored benefit that allows participants to set aside pre-tax funds from their paychecks to help them pay for approved out-of-pocket healthcare or dependent care expenses.
What is the dependent care FSA limit for 2025?
We will remain with Diversified Benefits Services (DBS) as our Flexible Spending Account vendor in 2025. The 2025 Maximum Health Care FSA election is $3,300 and the 2025 Maximum Dependent Care Election is $5,000.
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What is HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM?
The HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM is a document that allows employees to enroll in or make changes to their flexible spending accounts for eligible healthcare and dependent care expenses.
Who is required to file HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM?
Employees who wish to enroll in or modify their participation in the Health Care or Dependent Care FSA are required to file this form.
How to fill out HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM?
To fill out the form, employees should provide personal details, indicate their desired contribution amounts for both Health Care and Dependent Care FSAs, and sign the form to confirm their agreement.
What is the purpose of HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM?
The purpose of the form is to manage enrollment in flexible spending accounts, allowing employees to allocate pre-tax earnings for eligible medical and dependent care expenses.
What information must be reported on HEALTH CARE & DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT (FSA) ENROLLMENT OR CHANGE FORM?
The information required includes the employee's name, identification number, election amounts for Health Care and Dependent Care FSAs, and any changes to existing elections.
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