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FSA "Cafeteria Plans"Forms
Below you will find a variety of Cafateria Plan Forms and information is available in both a .pdf and .doc (MS Word) format. The forms can be printed, completed and then faxed or mailed.
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| Privacy Statement: .pdf (Adobe) / .doc (MSN Word)
HIPPA guidelines require that the privacy policy of a covered entity be disclosed to plan participants. This notice provides Worksite Benefit Plans, Inc.'s privacy policy and should be provided to all plan participants.
FSA Claim Form: .pdf (Adobe) / .doc (MSN Word)
Used when requesting reimbursements from your Medical and/or Dependent Care Accounts.
Allowable Over The Counter Items: /
This form provides a list of generally acceptable over the counter (OTC) items available for reimbursement. While these items are qualified you should consult with your Company's cafeteria plan to ensure they are allowable.
Direct Deposit Authorization: .pdf (Adobe) / .doc (MSN Word)
This form authorizes Worksite Benefit Plans, Inc. to create an ACH transfer (Direct Deposit) of your reimbursements into your personal checking or savings account. Most transfers take two to five business days. Note: Not all employers allow for Direct Deposit. If in doubt you should consult with your employer to see if Direct Deposit is available to you.
Change of Status Matrix for Plans W/Flexible Spending Accounts (FSA): .pdf (Adobe) / .doc (MSN Word)
This form provides a list of qualified changes allowed by Code. For additional information go to www.changeofstatus.com (note: not all changes listed are acceptable by your employer, if a change is in question you should consult your employer)
Change of Status Matrix for Premium Only (POP) Plans: .pdf (Adobe) / .doc (MSN Word)
This form provides a list of qualified changes allowed by Code. For additional information go to www.changeofstatus.com (note: not all changes listed are acceptable by your employer, if a change is in question you should consult your employer)
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