Forms & Documents

The following forms and documents are available for you to download in PDF format.

Debit Card Overview for participants enrolling in a Health Care FSA.

Claim form for participants.

If you want your monthly day care claim to be automatically filed each month, please complete this form.

Use this form to set up your monthly orthodontia payments as a recurring Health Care FSA claim.

Certain expenses require a provider’s authorization in order for them to be eligible for reimbursement. Complete this form for expenses that require a provider’s authorization.

If you would like to enroll in direct deposit for your reimbursements, or to request n debit card, please complete this form and return it to Navia Benefit Solutions.

If you would like to have another individual be able to call Navia Benefit Solutions to discuss your benefits and detailed information about your account, please complete this form.

Please make sure to download the latest version of Adobe Reader prior to opening the PDF documents above.

Contact us at (800) 669-3539, Monday – Friday from 5:00am to 5:00pm PST