Forms & documents
The following forms and documents are available for you to download in PDF format.
Current plan year
Read this guide to learn about the 2020 FSA program.
Read this guide to learn about the 2020 DCAP program.
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.
Enrollment form for newly eligible employees enrolling in a 2020 FSA or DCAP.
Claim form for participants in an FSA or DCAP for the 2020 plan year.
An overview of the Navia Benefits FSA Card for the 2020 plan year.
If you want your monthly day care claim to be automatically filed each month, please complete this form.
Use this form to set up your monthly orthodontia payments as a recurring FSA claim.
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.
If you would like to enroll in direct deposit for your FSA or DCAP reimbursements, or to request an FSA debit card, please complete this form and return it to Navia Benefit Solutions.
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.
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.
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.
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