Flexible Spending Account (FSA) and Health Savings Account (HSA) Forms

For questions or if another form is needed, please contact the DASFlex department directly at 605-322-4774 or dasflex@averahealthplans.com.

• Flexible Spending Eligible Expenses

• Administrative Services Agreement

• FSA Employee Application

• Flex Reimbursement Request

• Letter of Medical Necessity

• Flexible Spending Account Employer Set-up Request

• Premium-Only Plan Employer Set-up Request

• HSA Administrative Enrollment Form

• HSA Transfer Form

• HSA Employer Group Enrollment Application