Flexible Spending Account Forms 

Flexible Spending Account enrollment and election changes are regulated by the Internal Revenue Service (IRS). See the following to determine which form to use for your situation:

• If you are newly eligible to participate in the Flexible Spending account, use the 2024 Health Care and Dependent Care FSA Enrollment eForm (a downloadable version is available here)

• For Open Enrollment 2025, use the 2025 Health Care and Dependent Care FSA Enrollment eForm (a downloadable version is available here).

• If you have had a qualifying family status change that allows you to change your election amount or to participate in the Flexible Spending Account (because you were previously waived), complete and return a Request for Change in Status form:

  • Health Care FSA Request for Change in Status eForm (a paper version of the form is available here)
  • Dependent Care FSA Request for Change in Status eForm (a paper version of the form is available here)
  • Special Notes Regarding Change In Status Request Forms
    • Changes in deduction amounts will be effective the first day of the month following the receipt of the form. 
    • Please note that decreases cannot be less than amounts for which you have already received reimbursement from the plan.
    • The IRS does not permit a refund of pre-tax dollars that are contributed to an FSA.

Other Forms

• Dependent Care Provider's Identification and Certification
• Inspira Financial Health Care and Dependent Care FSA Claim Form

Flexible Spending Account Books

• 2024 Flexible Spending Accounts (effective Jan. 1 - Dec. 31, 2024)
• 2025 Flexible Spending Accounts (effective Jan. 1 - Dec. 31, 2025)

More Information on Flexible Spending Accounts

• What is an FSA?
• Inspira Financial Flexible Spending Account 
• Inspira Card - A guide to using the card.
• Stay Connected to Your Inspira Financial Account - Information on managing your account online and using the mobile app.
• Learn how to use an FSA to pay for dental expenses
• Inspira Financial Claim Filing Guidelines
• How to Keep Your Inspira Card Active