How to Fill Out and Submit the FSA Enrollment Form

An FSA enrollment form tells your employer how much of each paycheck, before taxes, to redirect into a flexible spending account for medical or dependent care costs. You fill it out once a year during open enrollment, choose an account type, and enter a single annual election amount. For 2026, that election can be up to $3,400 for a Health Care FSA1Internal Revenue Service. Eligible Employees Can Use Tax-Free Dollars for Medical Expenses or up to $7,500 for a Dependent Care FSA if you file jointly or as single/head of household ($3,750 if married filing separately).2Office of the Law Revision Counsel. 26 USC 129 – Dependent Care Assistance Programs The form is short. The number you put on it is the part worth thinking about, because you generally cannot change it until the next plan year.

What to Have Ready Before You Start

Whether the form is a paper page or a screen in your benefits portal, the fields are the same. Gather these before you begin:

  • Full legal name, Social Security number, and current home address. The plan administrator uses these to link the account to your tax ID.
  • Your account type choice: Health Care FSA, Dependent Care FSA, Limited Purpose FSA, or a combination.
  • Your annual election amount. This is the total you want deducted over the full plan year, not the per-paycheck figure.
  • Your pay frequency, so you can sanity-check the deduction: 26 pay periods for biweekly, 24 for semimonthly, 12 for monthly.

The form does not ask for receipts or proof of expected expenses. You are making a binding estimate.

Choose the Right Account Type

Many employers let you enroll in more than one type of FSA at the same time, each with its own election amount. One account does not draw from the other.

  • A Health Care FSA (HCFSA) covers qualified medical, dental, and vision expenses insurance does not pay: copays, deductibles, prescription drugs, eyeglasses, hearing aids, and certain over-the-counter products. The 2026 limit is $3,400.3FSAFEDS. Message Board
  • A Dependent Care FSA (DCFSA) pays for child care or elder care that lets you (and your spouse, if married) work. The 2026 ceiling is $7,500 for joint filers and single/head of household filers, $3,750 for married filing separately.2Office of the Law Revision Counsel. 26 USC 129 – Dependent Care Assistance Programs
  • A Limited Purpose FSA (LEX HCFSA) is a narrower version of the health care FSA restricted to dental and vision expenses. This is the version to pick if you also contribute to a Health Savings Account, because a standard HCFSA would disqualify you from HSA contributions. The $3,400 limit still applies.4FSAFEDS. Limited Expense Health Care FSA

If you want two accounts, the form will have separate election fields for each.

Set Your Annual Election

The election amount is the one field where a wrong number costs real money. Unspent FSA funds can be forfeited at year-end, so estimating carefully matters more than with most payroll elections.

For a Health Care FSA, add up what you expect to pay out of pocket for medical, dental, and vision costs over the coming year: insurance copays, prescriptions, planned procedures, contact lenses, orthodontia payments, and similar expenses. If you have a year of past claims to look at, start there and adjust for anything you know is coming, such as a surgery or new glasses. Stay at or below $3,400.3FSAFEDS. Message Board

For a Dependent Care FSA, the math is simpler because child care and elder care costs are predictable. Add up monthly day care, after-school program, or adult day care fees for the year and compare against the $7,500 (or $3,750) ceiling.

To check the per-paycheck impact, divide your annual election by your number of pay periods. A $2,600 Health Care FSA election on a biweekly schedule works out to $100 per pay period across 26 paychecks. Online portals often do this math automatically. Paper forms usually ask only for the annual total and let payroll handle the division.

Submitting the Form

Most employers now process FSA enrollment through an online benefits portal. You log in, pick your account type, enter your annual election, and confirm. The portal generates a digital record that serves as your signed election. If your workplace still uses paper, you sign the form and hand it to human resources or send a scanned copy through a secure channel. Either way, the form has to reach your plan administrator before the enrollment deadline closes.

You should receive a confirmation statement showing your elected amount, the per-paycheck deduction, and the effective start date. Read it right away. A typo, like electing $3,400 when you meant $340, is easy to fix before payroll processing locks in. After the enrollment window closes, changing it requires a qualifying life event.

When You Can Submit an Enrollment Form

There are only two times you can submit an FSA enrollment form: open enrollment, and within a window around a qualifying life event.

Open Enrollment

Open enrollment is the main opportunity, and it usually runs two to four weeks before the new plan year begins. For federal employees using FSAFEDS, open season runs from mid-November to mid-December.5FSAFEDS. Open Season Private employers set their own windows on a similar pattern. Elections take effect the first day of the new plan year, typically January 1.

FSA elections do not roll over automatically. Even if you want the same amount as last year, you have to submit a new form during every open enrollment. Skip it and you have no FSA for the coming year.

Qualifying Life Events

Outside open enrollment, you can enroll or change your election only after a qualifying life event. The IRS recognizes marriage, divorce, birth or adoption of a child, death of a spouse or dependent, a change in your or your spouse’s employment status that affects benefits eligibility, and a change in dependent care arrangements.6FSAFEDS. FAQs – What Is a Qualifying Life Event Your plan documents set the exact filing window. For federal employees, it runs from 31 days before to 60 days after the event.7FSAFEDS. Qualifying Life Events Quick Reference Guide Private plans commonly allow 30 to 60 days after the event; confirm the exact deadline with your plan administrator.

For births and adoptions, the change is retroactive to the child’s date of birth or placement. For other qualifying events, the effective date depends on your plan’s rules.6FSAFEDS. FAQs – What Is a Qualifying Life Event

After You Enroll

With a Health Care FSA, your entire annual election is available on the first day of the plan year, even though only one pay period’s worth has been deducted. This is the uniform coverage rule. If you elected $3,400 and have a $3,000 expense in January, you can spend the full amount right away; your employer fronts the difference and recovers it through the rest of the year’s payroll deductions. The rule does not apply to Dependent Care FSAs, where your available balance is only what you have actually contributed so far, minus prior reimbursements.

Most plan administrators issue an FSA debit card linked to your account. You swipe it at the pharmacy, doctor’s office, or vision center, and the payment draws directly from your balance. At certain merchants, eligible purchases auto-approve based on transaction codes. For anything that cannot be verified automatically, or if you paid out of pocket, you submit a reimbursement claim with an itemized receipt showing the provider’s name, the patient’s name, the date of service, a description of the service, and the cost. The IRS requires every FSA transaction to be substantiated, so keep receipts for the whole plan year even when a card charge went through cleanly.

Know the Forfeiture Rule Before You Commit to a Number

FSAs operate under use-it-or-lose-it: money left in your account at the end of the plan year is forfeited, and your employer keeps the unused funds to offset plan administration costs or reduce future contributions on a uniform basis.8Internal Revenue Service. IRS Notice 2013-71 – Modification of Use-or-Lose Rule for Health Flexible Spending Arrangements Conservative elections beat optimistic ones.

The IRS lets employers offer one, but not both, of two relief options:

Which one your plan offers (or whether it offers either) is spelled out in the plan document. Check before you write down an election amount. A $680 carryover cushion lets you elect a bit more aggressively; straight forfeiture argues for staying on the conservative side of your estimate.

If You Leave the Job Mid-Year

One boundary worth knowing before you elect: FSA contributions stop with your last paycheck. For a Health Care FSA, you generally cannot use the account for expenses incurred after your last day, though you typically have 60 to 90 days (per your plan) to submit claims for expenses from while you were still covered. COBRA continuation is sometimes available for a Health Care FSA, but only in the uncommon case where you have contributed significantly more than you have spent.9eCFR. 26 CFR 54.4980B-2 – Plans That Must Comply Factor that into your election if you already know a job change is likely during the plan year.