Flexible Spending Accounts

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FSA Program Guides, Brochures & Forms

• HIPAA Rights (For the HCFSA Program only)
• HCFSA Medical Necessity Form
• HCFSA HIPAA Form

• FSA Program Direct Deposit Form

Brochures and Enrollment/Change Forms

Plan Year 2020

• Plan Year 2020 Flexible Spending Accounts Program Brochure
• Plan Year 2020 FSA Enrollment/Change Form
• Plan Year 2020 MSC Health Benefits Buy-Out Waiver Enrollment/Change Form
• Plan Year 2020 MSC Premium Conversion Enrollment/Change Form
• Plan Year 2020 HCFSA/DeCAP SPD
• Plan Year 2020 MSC SPD

Plan Year 2019

• Plan Year 2019 Flexible Spending Accounts Program Brochure
• Plan Year 2019 FSA Enrollment/Change Form
• Plan Year 2019 MSC Health Benefits Buy-Out Waiver Enrollment/Change Form
• Plan Year 2019 MSC Premium Conversion Enrollment/Change Form
• Plan Year 2019 HCFSA/DeCAP SPD
• Plan Year 2019 MSC SPD

Procedures Guide

Plan Year 2020

• DeCAP 2020

• HCFSA 2020

Plan Year 2019

• DeCAP 2019

• HCFSA 2019

FSA Claims Forms

Please direct all written inquiries/correspondence and claims to the following mailing address:

New York City Flexible Spending Accounts Program
Bowling Green Station
P.O. Box 707
New York, NY 10274

Plan Year 2020

• 2020 DeCAP Claims Form
• 2020 HCFSA Claims Form

Plan Year 2019

• 2019 DeCAP Claims Form
• 2019 HCFSA Claims Form

Lost Check Claim

To submit a claim for a lost check from the Management Benefits Fund, the Dependent Care Assistance Program, or the Health Care Flexible Spending Account Program.

• Lost Check Claim Form