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Toll-Free: 1-877-372-3337
TTY Line: 1-800-952-0450
Email: fsafeds@adp.com
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Toll-Free FAX:
1-866-643-2245
Email: fsafeds@adp.com
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FSAFEDS Forms Printer Friendly

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 newer. 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. For best results, use Adobe Acrobat Reader 7.0. You may encounter some accessibility issues if you use a lower version of Adobe Acrobat Reader.

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.

  • Health Care Claim Form - Microsoft Word Version
    This document is available for those who require special software to access the web. It is read-only to minimize issues with submission through our automated system.

  • Dependent Care Claim Form - Microsoft Word Version
    This document is available for those who require special software to access the web. It is read-only to minimize issues with submission through our automated system.

Other Forms

  • Dependent Care Tax Credit Worksheet - Assists DCFSA participants in determining the best option between the Federal tax credit and a Dependent Care Flexible Spending Account.

  • Capital Expense Worksheet - helps to determine if your expense is eligible.

  • Mileage Worksheet - helps to track mileage to and from a medical provider.

  • Belated Enrollment Form - if you were unable to enroll during Open Season for reasons outside your control

  • EFT Form - Electronic Funds Transfer (EFT) enrollment form for direct deposit of FSA reimbursement

  • Letter of Medical Necessity Form

  • Qualifying Life Events Form - Notification, Election to Enroll or Change Enrollment for Qualifying Life Events
    (Note: When modifying your allotment due to a Qualifying Life Event, please remember that your annual amount cannot be less than $250.00 for either a dependent or health care FSA and cannot exceed $5,000 for dependent care or $2,500 for health care. For more information regarding eligibility requirements, see Qualifying Life Events Fact Sheet.)

  • FSAFEDS Condolence Letter - to submit information regarding the estate of an FSAFEDS participant in order for surviving dependent(s) to submit claims.

  • HEART Act - QRD Form - to submit a request for a Qualified Reservist Distribution (QRD).

  • HIPAA Authorization Form - to authorize use or disclosure of your individually indentifiable health information to specific persons or entities.

  • HIPAA Revoke Authorization Form - to revoke an authorization or restrict the use or disclosure of your individually identifiable health information.

  • FSAFEDS Consent Form - to authorize use or disclosure of your personal information regarding your Dependent Care FSA.

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