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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.

FSA/DCAP Enrollment Form Enrollment form for participants enrolling in an FSA or DCAP.
FSA with DCAP Claim Form Claim form for participants in an FSA or DCAP.
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.
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.
2014 FSA Enrollment Guide Read this guide to learn about the FSA program.
2014 DCAP Enrollment Guide Read this guide to learn about the DCAP program.
 

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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