Get the free Health Care Flexible Spending Account Claims Rollover Authorization Form

This form authorizes ASIFlex to treat health care claims as made under both the medical plan and FSA, allowing automatic application of eligible expenses to FSA dollars and reimbursement.

How to fill out health care flexible spending

How to fill out Health Care Flexible Spending Account Claims Rollover Authorization Form

1. Obtain the Health Care Flexible Spending Account Claims Rollover Authorization Form from your HR department or the benefits platform.
2. Read the instructions carefully to understand the requirements.
3. Fill in your personal information, including your name, employee ID, and contact information.
4. Specify the amount you wish to rollover in the appropriate section of the form.
5. Indicate the year of the claims you are rolling over.
6. Sign and date the form to certify that all information provided is accurate.
7. Submit the completed form to the designated department as instructed. Keep a copy for your records.

Who needs Health Care Flexible Spending Account Claims Rollover Authorization Form?

1. Employees who have unused funds in their Health Care Flexible Spending Account at the end of the plan year.
2. Employees who wish to transfer their unspent FSA balances to the next plan year.
3. Individuals who have experienced eligible medical expenses but have not yet claimed them.

For pdfFiller’s FAQs

What is Health Care Flexible Spending Account Claims Rollover Authorization Form?

The Health Care Flexible Spending Account Claims Rollover Authorization Form is a document used by individuals to request the rollover of unused funds from their health care flexible spending accounts (FSAs) to the next plan year.

Who is required to file Health Care Flexible Spending Account Claims Rollover Authorization Form?

Employees who have unused funds in their health care flexible spending accounts at the end of the plan year and wish to roll over those funds to the next year are required to file this form.

How to fill out Health Care Flexible Spending Account Claims Rollover Authorization Form?

To fill out the form, individuals need to provide their personal information, including name, employee ID, and the amount they wish to roll over. They must also sign and date the form before submitting it to their benefits administrator.

What is the purpose of Health Care Flexible Spending Account Claims Rollover Authorization Form?

The purpose of the form is to facilitate the rollover of unused FSA funds to the next plan year, allowing individuals to utilize their remaining balance for eligible medical expenses.

What information must be reported on Health Care Flexible Spending Account Claims Rollover Authorization Form?

The form must report personal information such as the employee's name, contact information, employee ID, the amount of funds to be rolled over, and any necessary signatures.