Benefits Forms: Flexible Spending Accounts Forms
IMPORTANT: All of the forms listed on these pages are in Adobe
Portable Document Format (PDF). If you do not already
have Adobe Acrobat Reader on your computer, you must download
and install Adobe
Acrobat Reader before you will be able to view
or print Benefits forms.
Enrollment Forms
For continuing employees wishing to enroll for 2010 (Open Enrollment):
2010 Flexible Spending Account Deduction Authorization Form for Open Enrollment
For new hires or newly eligible employees:
- 2009 Flexible Spending Account Deduction Authorization Form
- 2010 Flexible Spending Account Deduction Authorization Form
SHPS Flexible Spending Account Claim Forms
There are separate claim forms for health care and dependent care FSA expenses. Fax your completed claim form and supporting documentation to SHPS at 877-270-3922, a toll-free number dedicated to the exclusive use of U-M FSA participants.
- Health Care Flexible Spending Account Reimbursement Claim Form
- Dependent Care Flexible Spending Account Reimbursement Claim Form
- Health Care FSA Request for Change in Status
- Dependent Care FSA Request for Change in Status
- Electronic Fund Transfer (EFT) Form for SHPS Flexible Spending Accounts
- W-10 Dependent Care Provider's Identification and Certification
Every effort has been made to ensure the accuracy of the benefits information in this site. However, if any provision on the benefits plans is unclear or ambiguous, the Benefits Office reserves the right to interpret the plan and resolve the problem. If any inconsistency exists between this site and the written plans or contracts, the actual provisions of each benefit plan will govern. The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents.