Forms & Documents - Navia

Forms & Documents

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

Current Plan Year

2023 Mid-Year Enrollment Form

Enrollment Form for newly eligible participants enrolling in a 2023 Medical FSA, Limited Purpose FSA, or DCAP.

Medical FSA, Limited Purpose FSA, and DCAP 2023 Claim Form Claim form for the 2023 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.


2023 FSA Enrollment Guide

2023 FSA Overview

2023 FSA Eligible Expenses

Read these documents to learn about the 2023 FSA program.


2023 DCAP Enrollment Guide

2023 DCAP Overview

Read these documents to learn about the 2023 DCAP program.


2023 Limited Purpose FSA Enrollment Guide

2023 Limited Purpose FSA Overview

2023 Limited Purpose FSA Eligible Expenses

Read these documents to learn about the 2023 Limited Purpose FSA program.


Navia Benefits Card Overview

An overview of the Navia Benefits Card.

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.


Watch Navia’s recorded SEBB FSA & DCAP Plan Education Session to learn more about the 2023 plan year.

Print copy of the presentation can be downloaded here.

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