Forms & Documents - Navia

Forms & documents

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

Prior Plan Year

DCAP 2020 Claim Form
Claim form for participants with the DCAP benefit for the 2020 plan year.

Current Plan Year

2021 Enrollment Form

Enrollment form for newly eligible employees enrolling in a 2021 FSA or DCAP.

2021 FSA Enrollment Guide

Read this guide to learn about the 2021 FSA program.

2021 DCAP Enrollment Guide

Read this guide to learn about the 2021 DCAP program.

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) or Dependent Care Assistance Program (DCAP) election(s). Use this Form to report the change to your employer.

FSA & DCAP 2021 Claim Form

Claim form for participants in an FSA or DCAP for the 2021 plan year.

Navia Benefits Card Overview

An overview of the Navia Benefits Card for the 2021 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.

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.

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.

School Employment Transfer Form

If you enroll in the Medical 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 Medical FSA and DCAP. Use this Form to process the transfer.

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.

Educational video: Watch a presentation about the FSA and DCAP programs


HCA’s privacy notice: The Health Care Authority (HCA) will keep your information private as allowed by law. See our Privacy Notice.

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

Contact us at (800) 669-3539, Monday – Friday from 5:00am to 5:00pm PST

Upcoming Plan Year

2022 Mid-Year Enrollment Form Enrollment Form for newly eligible participants enrolling in a 2022 Medical FSA, Limited Purpose FSA, or DCAP.

2022 FSA Enrollment Guide

2022 FSA Overview

2022 FSA Eligible Expenses

Read these documents to learn about the 2022 FSA program.


2022 DCAP Enrollment Guide

2022 DCAP Overview

Read these documents to learn about the 2022 DCAP program.


2022 Limited Purpose FSA Enrollment Guide

2022 Limited Purpose FSA Overview

2022 Limited Purpose FSA Eligible Expenses

Read these documents to learn about the *NEW* 2022 Limited Purpose FSA program.

Register here to join one of our live FSA & DCAP Plan Education Sessions during Open Enrollment

Tuesday Oct 26, 2021 4:00 PM –

Tuesday Nov 09, 2021 4:00 PM –

Or watch the pre-recorded version anytime!