Flexible Spending Forms

Flexible Spending Account Form

FSA_FSAD_Election_Form_2021_Fillable.pdf 404.76 KB (Last Modified on January 13, 2021)

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HealthPartners Flexible Spending Health Care Claim Form

FSA Health Care Claim Form.pdf 62.3 KB (Last Modified on March 15, 2018)

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HealthPartners Flexible Spending Dependent Care Claim Form

Claims are administered by HealthPartners for claims status and specific questions contact HealthPartners.com or 952.883.5000

entry_181612.pdf 55.58 KB (Last Modified on December 8, 2017)

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HealthPartners Automatic Claims Submission Opt Out Form

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

cntrb_006266.pdf 425.2 KB (Last Modified on December 8, 2017)

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HealthPartners Direct Deposit Form

Use this form to start, stop or change direct deposits into your bank account. For further information contact HealthPartners.com or 952.883.5000

cntrb_005262.pdf 63.68 KB (Last Modified on December 8, 2017)

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SPPS Employee Forms