Health Care Plan (Medical and Dental Coverage) - University of Utah 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name, employee ID, address, email, and phone number. Ensure all details are accurate for processing.
3. Select the appropriate status change event from the provided options. This is crucial as it determines your eligibility for changes in your FSA election.
4. Indicate the date of your status change event. Remember that changes must be made within 90 days of this date.
5. Fill in the new election amounts for both Health FSA and Dependent Day Care FSA. Be mindful of the maximum limits set for each account.
6. Review the authorization statements carefully. By checking these boxes, you confirm your understanding of the terms related to your FSA elections.
7. Finally, sign and date the form to certify that all information provided is true and correct before submitting it through our platform.

Start using our platform today to easily manage your Health Care Plan forms online for free!