Flexible Spending Account (FSA) - Medical and Dependent Care

**This corresponds with Section D of the "Employee Benefits Guide."

Calendar Year 2023

To enroll in a flexible spending account, please obtain a link for the online form from your location's office.

• Flexible Benefits Plan Participation and Form Directions
• Open Enrollment Video (link)
• Information: Medical Flexible Spending Account Guide
• Information: Limited Flexible Spending Account Guide (Used with HSA)
• Information: Dependent Care Flexible Spending Account Handout
• Information: Contribution Limits and Changes (Note: DOW-R minimum is $150/calendar year)
• Information: FSA Calculator Worksheet (link)
• Information: Accessing Flexible Spending Account Information Online
• Information: Accessing Flexible Spending Account Information Mobile
• Information: WEX Debit Card
• Information: How to file your claim online (link)
• Information: FSA Eligible Expenses (link)
• Information: FSA Claim Substantiation
• Form: FSA Enrollment (1/1/2023 - 12/31/2023) Form D-2
• Form: FSA Printable Claim Form for all claims not filed online

Calendar Year 2022

• Flexible Benefits Plan Participation and Form Directions
• Information: FSA - The Medical Flexible Spending Account
• Information: FSA - Limited Purpose (Used with HSA)
• Information: Medical FSA Worksheet
• Information: FSA - The Dependent Care Flexible Spending Account
• Information: Dependent Care FSA Worksheet
• Information: Getting Reimbursed for Dependent Care Expenses
• Information: Accessing Flexible Spending Account Information Online
• Form: FSA Enrollment (1/1/2022 - 12/31/2022) Form D-2
• Form: Medical Expense Reimbursement Claim Form
• Form: Daycare Expense Reimbursement Claim Form
• Form: Qualifying Event Notification Form
• Form: Authorization for Direct Deposit Form - ONLY for Medical or Dependent Care Flex