fsa-forms-and-downloads

Office of Labor Relations


Employee Asst Pgrm Flex SpendingMgmt Benefits VDC Program

FSA Videos
Worksheets and Calculators
DeCAP
HCFSA
MSC Health Benefits Buy-Out Waiver
MSC Premium Conversion
FSA Forms and Downloads
FSA Frequently Asked Questions
Email FSA

FSA Videos

Worksheets and Calculators

DeCAP

HCFSA

MSC Health Benefits Buy-Out Waiver

MSC Premium Conversion

FSA Forms and Downloads

FSA Frequently Asked Questions

Email FSA


Flexible Spending Accounts

Important Notice

Please submit your forms and documents as follows:

1) Inquiries and questions can be sent via email to the Program.

2) Forms and documents can be submitted electronically to: https://nyc-fsa.leapfile.net

Please do not submit your form/document more than once. This will only delay processing.

You will immediately receive notification stating "Success! Your file has been received" upon completion of your document upload. You will not receive a separate email confirmation.

View step-by-step instructions and video

3) Mail completed forms/documents to:
The Flexible Spending Accounts Program
P.O. Box 707
Bowling Green Station
New York, NY 10274

4) Express mail forms/documents should be sent to:
NYC Flexible Spending Accounts Program
22 Cortlandt Street, 28th Floor
New York, NY 10007

Please check back periodically for updates

IMPORTANT - If you are currently receiving your reimbursement via check, please complete a Direct Deposit Form in order to receive reimbursement in a timely fashion. Do not mail your completed form to the address on the form. Please submit your completed form following the directions above.

Download Adobe Scan to convert your hardcopy documents into PDFs. Use your smart phone or tablet camera to take a picture of your paper form and Adobe Scan will convert it to a PDF. Adobe Scan mobile app is available for iPhone and Android.

FSA Program Guides, Brochures & Forms

HIPAA Rights (For the HCFSA Program only)

HCFSA Medical Necessity Form

HCFSA HIPAA Form

FSA 2025 FAQ's

FSA Program Direct Deposit Form

Brochures and Enrollment/Change Forms

Plan Year 2025

Plan Year 2025 Flexible Spending Accounts Program Brochure

Plan Year 2025 FSA Enrollment/Change Form

Plan Year 2025 MSC Health Benefits Buy-Out Waiver Enrollment/Change Form

Plan Year 2025 MSC Premium Conversion Enrollment/Change Form

Plan Year 2025 HCFSA/DeCAP SPD

Plan Year 2025 MSC SPD

Plan Year 2024

Plan Year 2024 Flexible Spending Accounts Program Brochure

Plan Year 2024 FSA Enrollment/Change Form

Plan Year 2024 MSC Health Benefits Buy-Out Waiver Enrollment/Change Form

Plan Year 2024 MSC Premium Conversion Enrollment/Change Form

Plan Year 2024 HCFSA/DeCAP SPD

Plan Year 2024 MSC SPD

Procedures Guide

Plan Year 2025

DeCAP 2025

HCFSA 2025

Plan Year 2024

DeCAP 2024

HCFSA 2024

FSA Claims Forms

Please direct all inquiries/correspondence and claims as follows:
1) Contact the FSA Administrative Office at (212)306-7760 or (212)306-7789 between 9:00 a.m. and 4:00 p.m., Monday through Friday.
2) Inquiries and questions can be sent via email to the Program.
3) Forms/documents can be submitted electronically to: https://nyc-fsa.leapfile.net

Plan Year 2025

2025 DeCAP Claims Form

2025 HCFSA Claims Form

Plan Year 2024

2024 DeCAP Claims Form

2024 HCFSA Claims Form

Lost Check Claim

To submit a claim for a lost check from the Management Benefits Fund, the Dependent Care Assistance Program, or the Health Care Flexible Spending Account Program.

Lost Check Claim Form