Tip for Employer-specific

Healthcare FSAs are use-it-or-lose-it — estimate your expenses carefully. Some plans offer a $640 rollover or 2.5-month grace period

Tip for Employer-specific

The full healthcare FSA election is available on January 1 — even though you contribute throughout the year

Tip for Employer-specific

Dependent care FSAs are different — only the amount contributed so far is available for reimbursement

Tax-Related Healtheasy

FSA Enrollment Form

Employer-specific · Employer / FSA administrator

Election to participate in a Flexible Spending Account during open enrollment. Specifies annual pre-tax contribution amount. Use-it-or-lose-it rules apply (with possible carryover or grace period).

Form Details

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Filled by: patient
Frequency: annual

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Where to Submit This Form

🌐

Enroll through your employer's benefits portal during open enrollment

Most employers use online enrollment systems (Workday, ADP, Benefitfocus, etc.).

🏢

Submit enrollment form to your HR/benefits department

Paper enrollment may be available during your employer's open enrollment period.

Filing Deadline

During your employer's annual Open Enrollment period (typically October-November for January start). Also available within 30 days of a qualifying life event.

Required Attachments

📎 Completed FSA enrollment form or online election
📎 Elected annual contribution amount (healthcare FSA and/or dependent care FSA)

Processing Time

Elections are effective at the start of the plan year (typically January 1). Pre-tax deductions begin with the first payroll of the plan year.

What Happens Next

Your elected FSA amount will be divided evenly across paychecks as pre-tax deductions. You will receive an FSA debit card or can submit claims for reimbursement. The full annual election is available on Day 1 of the plan year for healthcare FSAs.

Tips for This Form

✓ Healthcare FSAs are use-it-or-lose-it — estimate your expenses carefully. Some plans offer a $640 rollover or 2.5-month grace period
✓ The full healthcare FSA election is available on January 1 — even though you contribute throughout the year
✓ Dependent care FSAs are different — only the amount contributed so far is available for reimbursement
✓ You cannot have both a traditional healthcare FSA and an HSA — but limited-purpose FSAs (dental/vision only) are compatible with HSAs

More Tax-Related Health Forms

Premium Tax Credit (PTC)

Form 8962 · Internal Revenue Service

Reconciles advance premium tax credit (APTC) payments with actual PTC eligibility based on final income. Required if you or a family member received APTC through the Marketplace. Failure to file blocks future APTC.

Health Insurance Marketplace Statement

Form 1095-A · Health Insurance Marketplace

Shows months of Marketplace coverage, premiums, and APTC paid. Sent to enrollees by mid-February. Used to complete Form 8962.

Health Coverage (1095-B)

Form 1095-B · Health insurance companies / Medicaid agencies

Shows who was covered and which months. Sent by insurers and Medicaid agencies. Not filed with tax return but should be kept as a record of coverage.

Employer-Provided Health Insurance Offer and Coverage

Form 1095-C · Large employers (50+ FTE)

Reports health coverage offered by employer. Sent to employees by March 2. May be used to determine PTC eligibility.

Health Savings Accounts (HSA)

Form 8889 · Internal Revenue Service

Reports HSA contributions and distributions. Must be filed if you had any HSA activity during the year. Part 1 covers contributions (potential tax deduction).

FSA / HSA Reimbursement Claim

Administrator-specific · FSA/HSA administrator

Request for reimbursement of qualified medical expenses from FSA or HSA. Requires documentation of expenses (receipts, EOBs).

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Employer / FSA administrator or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.