EMPOWER
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Advanced Flex Plan Administration with the Human Touch

Participant Resources for all Benefits

This page provides you with all forms and instructional guides for your EMPOWER Plan.

This page shows resources for all benefits. If you wish to view only the resources for your Plan, click the appropriate button below.

Table of Contents

Forms

EMPOWER encourages you to use the Online Portal to ensure the fastest service (see the Instructional Guides and Tutorials section below for more information). However, forms are provided below for you to fill out and return to EMPOWER as an alternate way to use your benefits.

Change in Status/Qualifying Event Form

Required for mid-year changes to your FSA

Direct Deposit Authorization Form

Add or change an existing bank account to receive reimbursements right to your bank account

FSA Claim Form

Use this form to submit an FSA claim.

HRA Claim Form

Use this form to submit an HRA claim.

HSA Beneficiary Form

Use this form to add or change an HSA beneficiary.

HSA Claim Form

Use this form to submit an HSA claim.

HSA Contribution Change Form

Use this form to make a change to your HSA contributions.

HSA Contribution Form

Use this form to make an HSA contribution outside of your Employer’s payroll.

HSA Custodial Agreement

All HSA participants must either accept the HSA terms on the Consumer portal or sign this form and return the last page to EMPOWER.

HSA Transfer Form

Form to transfer the balance from another account to your current EMPOWER HSA account.

QSEHRA Claim Form

This form allows participants to seek reimbursement from the QSEHRA.

Additional Resources

Eligible Items

List of eligible items for all plans.

HSA Investment Options

List of HSA investment options.

Instructional Guides and Tutorials

FSA Welcome Guide (PDF)

Comprehensive guide to using your EMPOWER FSA.

FSA Welcome Page (Online)

Comprehensive online guide to using your EMPOWER FSA.

HRA Plan Fact Sheet (PDF)

Details the plan-specific details of your HRA.

  1. Log into the EMPOWER Online Portal.
  2. Click on Tools & Support.
  3. On the Tools & Support Page, click on the HRA Plan Fact Sheet link to download.

HRA Welcome Page (Online)

Online guide to using your EMPOWER HRA.

QSEHRA Welcome Guide

PDF Guide that explains the QSEHRA.

HSA Welcome Guide (PDF)

Comprehensive guide to using your EMPOWER HSA.

HSA Welcome Page (Online)

Comprehensive online guide to using your EMPOWER HSA.

Online Portal Quick Start Guide for FSA and HRA

Learn how to use the Online Portal (FSA and HRA).

Online Portal Quick Start Guide for HSA

Learn how to use the Online Portal (HSA).

EMPOWER Participant
Mobile App Download

If you have an FSA, HRA, or HSA with EMPOWER, we encourage you to
download the Mobile App to manage your benefits on the go!
Apple iOS
Google Android

EMPOWER LOGIN

I am a Participant
Click the above link if you are a participant who has an FSA, HSA, or HRA with EMPOWER.
I am an Employer
Click the above link if you are an Employer or Consultant.

Download Forms

Click one of the links below to view the available forms.

I am a Participant
Click the above link if you are a participant who has an FSA, HSA, or HRA with EMPOWER.
I am an Employer
Click the above link if you are an Employer or Consultant.