Get the free (FSA) Enrollment/Change form - Priority Health

Priority FSA Enrollment/change form SM Attention: AS Flex MS 2260 1231 East Belt line NE Grand Rapids, MI 49525-4501 Fax to 616.942.5242 I am completing this form for (check all that apply): FSA enrollment

How to fill out fsa enrollmentchange form

How to Fill Out FSA Enrollment Change Form:

1. Start by obtaining the FSA Enrollment Change Form from your employer or insurance provider. It may also be available on their website or through your online account.
2. Read the instructions carefully, as they will provide important information about what changes you can make to your FSA enrollment.
3. Begin by entering your personal information, such as your full name, date of birth, and employee ID number, in the designated fields on the form.
4. Indicate the effective date of the enrollment change. This is the date from which the change will take effect, and it is important to select the appropriate date to avoid any confusion.
5. Specify the change you wish to make in your FSA enrollment. This may include adding or removing dependents, changing the coverage level, or modifying the contribution amount.
6. If applicable, provide the necessary supporting documentation to accompany your enrollment change request. This may include birth certificates, marriage certificates, or proof of legal guardianship.
7. Double-check all the information you have provided to ensure accuracy. Mistakes or omissions may delay the processing of your request.
8. Sign and date the form to certify that the information provided is accurate and complete.
9. Submit the completed form to the designated entity. This may be your employer's human resources department or the health insurance provider. Follow any additional instructions regarding submission procedures or deadlines.

Who Needs FSA Enrollment Change Form:

1. Employees who currently have a flexible spending account (FSA) and wish to make changes to their enrollment.
2. Individuals who have experienced a qualifying life event, such as getting married, having a child, or adopting a dependent, and need to update their FSA coverage accordingly.
3. Employees who want to adjust their FSA contribution amount for the upcoming plan year, usually during the open enrollment period.
4. Those who want to remove a dependent from their FSA coverage due to a change in their circumstances, such as a child reaching the age limit or a divorce/separation.

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What is fsa enrollmentchange form?

The fsa enrollmentchange form is a form used to make changes to your Flexible Spending Account (FSA) enrollment.

Who is required to file fsa enrollmentchange form?

Employees who want to make changes to their FSA enrollment are required to file the fsa enrollmentchange form.

How to fill out fsa enrollmentchange form?

To fill out the fsa enrollmentchange form, you need to provide your personal information, select the changes you want to make to your FSA enrollment, and submit the form to your benefits administrator.

What is the purpose of fsa enrollmentchange form?

The purpose of the fsa enrollmentchange form is to allow employees to make changes to their FSA enrollment such as updating contribution amounts or adding dependents.

What information must be reported on fsa enrollmentchange form?

The fsa enrollmentchange form requires information such as employee name, employer information, FSA plan details, and the changes being made to the enrollment.