Forms & DocumentsThe following forms and documents are available for you to download in PDF format.
Current Plan Year Forms
2024 Mid-Year Enrollment Form: Enrollment Form for newly eligible participants enrolling in a 2024 Medical FSA, Limited Purpose FSA, or DCAP.
Medical FSA, Limited Purpose FSA, and DCAP 2024 Claim Form: Claim form for the 2024 plan year.
DCAP Recurring Claim Form: 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.
HIPAA Release Form: If you would like to have another individual be able to call Navia Benefit Solutions to discuss your benefits and detailed information about your account, please complete this form.
Direct Deposit and Debit Card Form: If you would like to enroll in direct deposit for your FSA or DCAP reimbursements, or to request a debit card, please complete this form and return it to Navia Benefit Solutions. Alternatively, you can request these changes online by logging into your Navia member portal.
Change in Status Form: If you experience a qualified special open enrollment (SOE) event, you may be eligible to enroll or change your Medical Flexible Spending Arrangement (FSA), Limited Purpose FSA, or Dependent Care Assistance Program (DCAP) election(s). Use this Form to report the change to your employer.
School Employment Transfer Form: If you enroll in a Flexible Spending Arrangement (FSA) and/or Dependent Care Assistance Program (DCAP) and later change jobs to work at another Washington State school district, educational service district, or charter school, your enrollment may continue if your new position is eligible for participation in the SEBB Program FSA and DCAP. Use this Form to process the transfer.
FSA Termination Form: If you end employment during the plan year or you retire, complete and sign this form, then return it to your employer’s personnel, payroll, or benefits office within 30 calendar days of your SEBB benefit end date.
Benefit Documents
Read these documents to learn about your 2024 FSA program.
Read these documents to learn about the 2024 DCAP program.
Read these documents to learn about the 2024 Limited Purpose FSA program.
2024 Limited Purpose FSA Enrollment Guide
2024 Limited Purpose FSA Eligible Expenses
Watch Navia’s recorded SEBB FSA & DCAP Education Session to learn more about the 2024 plan year.
HCA’s privacy notice: The Health Care Authority (HCA) will keep your information private as allowed by law. See our Privacy Notice.
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Questions
Contact us at (800) 669-3539, Monday – Friday from 5:00am to 5:00pm PST