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Advanced Flex Plan Administration with the Human Touch

Resources for FSAs

This page provides Employer and participant resources, forms, and guides for Flexible Spending Accounts (FSA).

This page shows resources to help you administer your EMPOWER FSA. If you would like to view our Enrollment Resources page that has helpful information for enrollment, click the link below.

Table of Contents

Forms

Participant Forms

Name

Description

English

Spanish

Change in Status/Qualifying Event Form

Required for mid-year changes to an 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.

FSA Enrollment Form

This is an enrollment form that you may distribute to your employees. This includes Health and Dependent Care FSAs.

FSA Enrollment Form (with Limited Purpose FSA)

Use this enrollment form if you have an FSA and Limited Purpose FSA

Employer Forms

Name

Description

English

Spanish

Banking Setup Form

Use this form to set up your Employer bank account with EMPOWER.

FSA COBRA Form

Use this form to send to terminated Employees to elect COBRA.

Nondiscrimination Questionnaire

Form for Employers to submit information for nondiscrimination testing.

Enrollment Methods

Name

Description

English

Spanish

Enrollment Spreadsheet

Use this link to download the enrollment spreadsheet to send you enrollments to EMPOWER.

EMPOWERConnect

EMPOWERConnect is an optional service that automatically integrates with your HRIS or Payroll system.

Instructional Guides

Participant Instructional Guides

Name

Description

English

Spanish

FSA Welcome Guide (PDF)

Comprehensive guide to using the EMPOWER FSA.

Coming Soon

FSA Welcome Guide (Online)

Comprehensive guide to using the EMPOWER FSA.

Coming Soon

Participant Portal Quick Start Guide

Learn how to use the Online Portal.

Coming Soon

Employer Instructional Guides

Name

Description

English

Employer Welcome Guides

Guides are available that explain how to administer your EMPOWER Plan.

You will receive guides when setting up a new plan and during open-enrollment. Ask your Account Administrator for additional information.

Employer Portal Quick Start Guide

Use this guide to learn how to use the Employer Online Portal.

PCORI Guide

Read this guide to determine if you are required to pay PCORI fees to the IRS.

Additional Resources

Participant Resources

Name

Description

English

Spanish

Eligible Items

List of eligible items for all Plans.

Coming Soon

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 Devices

Google Android Devices

EMPOWER LOGIN

I am a Participant

I am an Employer

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

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.