EMPOWER
Resources for FSAs
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.

Coming Soon

Direct Deposit Authorization Form

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

Coming Soon

FSA Claim Form

Use this form to submit an FSA claim.

Coming Soon

FSA Enrollment Form

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

Coming Soon

FSA Enrollment Form (with Limited Purpose FSA)

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

Coming Soon

Forms

Employer Forms

Name
Description
English
Spanish

Autopay Enrollment Form

Use this form to auto pay your EMPOWER invoices.
Coming Soon

Banking Setup Form

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

Coming Soon

FSA COBRA Form

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

Coming Soon

Nondiscrimination Questionnaire

Form for Employers to submit information for nondiscrimination testing.

Coming Soon

Payroll Frequency Change Form

Use this form to request mid-year payroll frequency changes

Coming Soon

Enrollment Methods

Name
Description
English
Spanish

Enrollment Spreadsheet

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

Coming Soon

EMPOWERConnect

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

Coming Soon

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

Instructional Guides

Employer Instructional Guides

Name
Description
English
Spanish

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.

Coming Soon

PCORI Guide

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

Coming Soon

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
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.