FLEXIBLE BENEFITS FORMS
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The plan member must complete this form each year during annual enrollment to enroll into a Flexible Spending Arrangement (FSA). New hires have 30-days in which to decide to enroll in a FSA and complete this form. |
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Plan members enrolled in a Dependent Care FSA must use this form for recurring dependent expenses. It must be completed each year you enroll and re-enroll in the Dependent Care FSA. |
Optum Financial FSA Claim Form (Effective June1, 2022) |
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Optum Financial Dependant Care Claim Form (Effective June1, 2022) |