Flexible Spending Accounts
Note regarding 2016 FSA funds: 2016 eligible expenses/services can be incurred through March 15, 2017 and must submitted by June 15, 2017.
Elect your 2017 FSA during open enrollment! Be sure to write in the amount you want for the ENTIRE YEAR on your form.
- Maximum election amount for 2017 Health Care FSA: $2,500 per employee
- Maximum election amount for 2017 Dependent Daycare FSA: $5,000 per family
PacificSource Administrators Resources
How much should you contribute to your flexible spending account? Use PacificSource's handy expense worksheet to help you estimate.
You can also submit a claim by fax or mail using the FSA Reimbursement Form
- Fax: (866) 446-6090
- PacificSource Administrators
PO Box 2797
Portland, OR 97208-2797
Want to know more about your flexible spending account? Check out these great resources:
- Examples of Eligible Expenses
- FSA User’s Guide
- Benny Card Guide
- FSA Grace Period FAQ
- Flexible Spending Account Summary Plan Description
Other Useful Forms:
- Letter of Medical Necessity
- Direct Deposit Authorization (to have reimbursed funds directly deposited into your bank account)
- Dependent Care Recurring Expense Form (to have dependent care funds automatically reimbursed to you)