Forms: Flexible Spending Account (FSA)

Below are some forms for the Flexible Spending Account plans. Original mid year enrollment change forms must be received by the Benefits Divsion. Copies, faxes and .pdf files will not be accepted.

2008 Calendar Year Forms

Mid Year Enrollment form

Use this form to enroll in a plan or change enrollment as a result of a qualifying change in family or employmjent status. The Benefits Division must receive the completed enrollment form within 31 days of the qualifying change in status.

Claim Reimbursement

Health and related expenses: Reimbursement for out of pocket health, dental and vision related services received during calendar year 2008 may be obtained by using the convenient PayFlex debit card. Most health related merchants accept the Debit Card. If you did not receive a card, you may obtain one by contacting PayFlex directly at 800 284-4885.

You may alternatively initiate the claim reimbursement process by accessing the PayFlex web site, completing a claim online, printing the claim form, attaching receipts and submitting the claim and receipts by fax directly to PayFlex. Claim reimbursement occurs within 2-3 days. Your member ID is your NU employee ID found on your Wildcard.

The third method is to download a PayFlex claim form and submitting the form directly to PayFlex.

Remember, unlike the dependent care account, you may be reimbursed up to your total annual pledge amount regardless of your account balance.

Dependent (child care) expenses: Reimbursement for child care related services may be obtained by completing a claim online or by downloading a claim form and submitting it directly to PayFlex. Your member ID is your NU employee ID found on your Wildcard. The amount of reimbursement is dependent upon your account balance.

The deadline for submitting 2008 claims is the end of February, 2009. Any account balance as of March 1st 2009 is forfeited.

FSA claim reimbursement forms should not be submitted to the University's Benefits Division as it is no longer processes FSA claims.