EMPOWER
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Advanced Flex Plan Administration with the Human Touch

Resources for all Benefits

This page provides Employer and participant resources, forms, and guides for all Benefits.
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

Participant Forms

Name
Description
Plan
English
Spanish
Change in Status/Qualifying Event Form
Required for mid-year changes to an FSA.
FSA
Direct Deposit Authorization Form
Add or change an existing bank account to receive reimbursements right to your bank account
All Plans
FSA Claim Form
Use this form to submit an FSA claim.
FSA
FSA Enrollment Form
This is an enrollment form that you may distribute to your employees. This includes Health and Dependent Care FSAs.
FSA
FSA Enrollment Form (with Limited Purpose FSA)
Use this enrollment form if you have an FSA and Limited Purpose FSA
FSA
LPFSA
HRA Claim Form
Use this form to submit an HRA claim.
HRA
HSA Beneficiary Form
Use this form to add or change an HSA beneficiary.
HSA
HSA Claim Form
Use this form to submit an HSA claim.
HSA
HSA Contribution Form
Use this form to make an HSA contribution outside of your Employer’s payroll.
HSA
HSA Contribution Change Form
Use this form to make a change to your HSA contributions.
HSA
HSA Custodial Agreement
All HSA participants must either accept the HSA terms on the Online Portal or sign this form and return the last page to EMPOWER.
HSA
HSA Enrollment Form
This is an enrollment form that you may distribute to your employees.
HSA
HSA Transfer Form
Form to transfer the balance from another account to the participant’s current EMPOWER HSA account.
HSA
QSEHRA Claim Form
This form allows participants to seek reimbursement from the QSEHRA.
QSEHRA
QSEHRA Enrollment Form
This form allows participants to attest to minimum essential coverage.
QSEHRA

Forms

Employer Forms

Name
Description
Plan
English
Spanish
Autopay Enrollment Form
Use this form to auto pay your EMPOWER invoices.
All Plans
Banking Setup Form
Use this form to set up your Employer bank account with EMPOWER.
All Plans
FSA COBRA Form
Use this form to send to terminated Employees to elect COBRA.
All Plans
Nondiscrimination Questionnaire
Form for Employers to submit information for nondiscrimination testing.
All Plans

Enrollment Methods

Name
Description
Plan
English
Spanish
Enrollment Spreadsheet
Use this link to download the enrollment spreadsheet to send you enrollments to EMPOWER.
All Plans
EMPOWERConnect
EMPOWERConnect is an optional service that automatically integrates with your HRIS or Payroll system.
All Plans

Instructional Guides

Participant Instructional Guides

Name
Description
Plan
English
Spanish
FSA Welcome Guide (PDF)
Comprehensive guide to using the EMPOWER FSA.
FSA
Coming Soon
FSA Welcome Guide (Online)
Comprehensive guide to using the EMPOWER FSA.
FSA
Coming Soon
HRA Welcome Guide (Online)
Comprehensive guide to using the EMPOWER FSA.
HRA
Coming Soon
HRA Plan Fact Sheet
A single page handout that contains specific details about your Plan.
HRA
Your Account Manager will email this to the Employer before open enrollment starts.
HSA Welcome Guide (PDF)
PDF guide that details the HSA Plan for new participants.
HSA
Coming Soon
HSA Welcome Guide (Online)
Comprehensive guide to using the EMPOWER HSA.
HSA
Coming Soon
Participant Portal Quick Start Guide
Learn how to use the Online Portal (FSA and HRA).
FSA
HRA
Coming Soon
Participant Portal Quick Start Guide
Learn how to use the Online Portal (HSA).
HSA
Coming Soon
QSEHRA Welcome Guide
PDF Guide that explains the QSEHRA for participants.

QSEHRA

Coming Soon

Instructional Guides

Employer Instructional Guides

Name
Description
Plan
English
Spanish
Employer Welcome Guides
Guides are available that explain how to administer your EMPOWER Plan.
All Plans
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.
All Plans
Coming Soon
PCORI Guide
Read this guide to determine if you are required to pay PCORI fees to the IRS.
FSA
HRA
Coming Soon

Additional Resources

Participant Resources

Name
Description
Plan
English
Spanish
Eligible Items
List of eligible items for all Plans.
All Plans
Coming Soon
HSA Investment Options
List of HSA Investment Options
HSA
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.