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Welcome to Flex-Plan Services for State of Washington Employees
 

Forms & Documents

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The following forms and documents are available for you to download in PDF format.

2015 Open Enrollment Kit Enrollment kit for participants enrolling in an FSA or DCAP.
2015 FSA Enrollment Guide Read this guide to learn about the 2015 FSA program.
2015 DCAP Enrollment Guide Read this guide to learn about the 2015 DCAP program.
2015 Midyear Enrollment Form Eligible new hire employees may use this form to enroll in the FSA and/or DCAP during their enrollment period within the plan year. Return the completed form to your personnel, payroll, or benefits office for processing.
Debit Card Overview Debit Card Overview for participants enrolling in an FSA.
FSA with DCAP 2014 Claim Form Claim form for participants in an FSA or DCAP for the 2014 plan year.
FSA with DCAP 2015 Claim Form Claim form for participants in an FSA or DCAP for the 2015 plan year.
Recurring Day Care Claim Instruction Guide Read this guide to learn how to submit a recurring day claim through your online profile.
DCAP Services Contract If you want your monthly day care claim to be automatically filed each month, please complete this form.
Orthodontia Contract Use this form to set up your monthly orthodontia payments as a recurring FSA claim.
Letter of Medical Necessity Certain expenses require a provider's authorization in order for them to be eligible for reimbursement. Complete this form for expenses that require a provider's authorization.
Termination Form If you cease employment during the plan year, please review and complete this form. Return the completed form to your personnel, payroll, or benefits office for processing.
Change of Status Form If you have experienced a qualifying event and would like to make a corresponding change in your annual election, complete this form and return it to your personnel, payroll, or benefits representative.
Direct Deposit and Debit Card Form If you would like to enroll in direct deposit for your FSA or DCAP reimbursements, or to request an FSA debit card, please complete this form and return it to Flex-Plan Services.
HIPAA Release Form If you would like to have another individual be able to call Flex-Plan Services to discuss your benefits and detailed information about your account, please complete this form.
Agency Transfer Form If you have terminated employment with an agency and been rehired within 30 days with a new agency, complete this form to continue your FSA or DCAP benefits.
 

HCA's Privacy Notice: The Health Care Authority (HCA) will keep your information private as allowed by law. To see our Privacy Notice, go to www.hca.wa.gov/pebb.

Please make sure to download the latest version of Adobe Reader prior to opening the PDF documents above.

 

 

 

 

Questions? Contact us at (800) 669-3539 (FLEX), Monday - Friday from 6:00am to 6:00pm

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