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contact information
FSAFEDS 24 Hour Fax Line: 502-267-2233
Customer Service: 1-877-FSAFEDS (372-3337)
E-mail:
fsafeds@shps.net
FSAFEDS TTY Line: 1-800-952-0450
HIPAA
SHPS and the Office of Personnel Management (OPM) are committed to keeping personal information secure and maintaining the confidentiality of all information received from customers and Web site users. OPM will not have access to any Protected Health Information (PHI) as defined by the new HIPAA Privacy Standards. In addition, please be assured that SHPS has privacy protections built into every aspect of their business operations, including Web-based services. For more detailed information, read the Privacy Statement below.

bullet Download SHPS Privacy Statement


The forms and brochures are available here in Adobe Acrobat Reader (.pdf format), which is free and easily accessible. to download Acrobat.
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Forms and Brochures
Download Instructions
The forms and brochures are available here in Adobe Acrobat Reader (.pdf format), which is free and easily accessible. Click here to download Acrobat.
  • The documents here are best viewed using Acrobat Reader version 4.0 or newer.  Simply click on the Adobe link above to download the software. If you experience difficulties with the documents, please access Troubleshooting Adobe Acrobat Reader for help.

  • These documents are specific to FSAFEDS and are designed to give you an overview of the FSAFEDS Program.

  • The claim forms are in an interactive format allowing you to input all applicable information.

Flexible Spending Accounts:
Health Care and Dependent Care
  • Dependent Care Tax Credit Worksheet - Assists DCFSA participants in determining the best option between the Federal tax credit and a Dependent Care Flexible Spending Account.

Submission Forms
  • Absentee Enrollment Form - if you are unable to enroll during Open Season for reasons outside your control

  • Claim Form - PDF Fillable - To submit eligible expenses for reimbursement
    (Note: To save to your desktop, right click on the above "Claim Form – PDF Fillable" link and select Save As.  You can now name the file and save to your computer.)

  • Claim Form - Microsoft Word - To submit eligible expenses for reimbursement. This form can only be viewed using Microsoft Word. With this form information can be entered and saved to your local machine.

  • EFT Form - Electronic Funds Transfer (EFT) enrollment form for direct deposit of FSA

  • Certification of Medical Necessity Form

  • Qualified Status Changes Form - Notification, Election to Enroll or Change Enrollment for Qualified Status Changes
    (Note: When modifying your allotment due to a Qualified Status Change, please remember that your annual amount cannot be less than $250.00 for either a dependent or health care FSA and cannot exceed $5,000 for dependent care or $4,000 for health care.  For more information regarding eligibility requirements, see Qualified Status Changes Fact Sheet.)

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