Flexible Spending Forms
This form is a fillable PDF.
1 - Download the form to your computer
2 - Fill it out on your computer, save
3 - Email completed form to email@example.com
Use this form when:
New Hire - Do not use this form, election is made when completing your benefits enrollment online.
Qualifying Status Change - Change in daycare
This form is not used during Open Enrollment. Online enrollment required annually.
Claims are administered by HealthPartners for claims status and specific questions contact HealthPartners.com or 952.883.5000
Use this form to opt out of automatic medical flexible spending reimbursement. All reimbursements from your FSA will be a manual process. For further information contact HealthPartners.com or 952.883.5000