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.
Enroll in an FSA
- 2015 Flexible Spending Account Deduction Authorization Form (for new hires and newly eligible faculty and staff only)
- For Open Enrollment 2015 FSA elections, use the 2015 FSA Open Enrollment form. Enroll by 12/31/14. Funds will be available for reimbursement after 2/1/15.
Change in Status Forms
You have the option of submitting a claim online or completing a paper claim form and mailing or faxing it along with your itemized documentation.
Submitting Claims Online
See the FSA Claims page for instructions on filing claims online.
Submitting a Paper Claim via Mail or Fax
- Login to your HealthHub account at umich.healthhub.com and select My HealthHub Resources to download a claim form from Administrative Forms.
- Complete the fillable Form by entering your claim information.
• Print and sign the form.
• Mail the completed form and itemized receipts to:
PayFlex Systems USA
P.O. Box 3039
Omaha, NE 68103-3039
(Or) FAX the completed form along with the itemized
receipts to (402) 231-4310