Benefits Forms: Flexible Spending Accounts Forms

IMPORTANT: All of the forms listed on these pages are in Adobe Portable Document Format (PDF). If you do not already have Adobe Acrobat Reader on your computer, you must download and install Adobe Acrobat Reader before you will be able to view or print Benefits forms.

Forms

For New Hires or Newly Eligible

• 2013 Flexible Spending Account Deduction Authorization Form

For enrolling after Open Enrollment (enroll by December 31, 2012)

• 2013 Flexible Spending Account Deduction Authorization Form (OE)

Change in Status Forms

• Health Care FSA Request for Change in Status
• Dependent Care FSA Request for Change in Status

W-10 Form

• W-10 Dependent Care Provider's Identification and Certification

Filing Claims

You have the option of submitting a claim online or completing a paper claim form and mailing or faxing it along with your itemized documentation.

Submitting Claims Online

See the FSA Claims page for instructions on filing claims online.

Submitting a Paper Claim via Mail or Fax

1. Login to your HealthHub account at umich.healthhub.com and select My HealthHub Resources to download a claim form from Administrative Forms.
2. Complete the fillable Form by entering your claim information.
   • Print and sign the form.
   • Mail the completed form and itemized receipts to:
   
   PayFlex Systems USA
   P.O. Box 3039
   Omaha, NE 68103-3039
   
   (Or) FAX the completed form along with the itemized
   receipts to (402) 231-4310