MEDICAL FLEXIBLE SPENDING PROGRAM …

MEDICAL FLEXIBLE SPENDING PROGRAM ( medflex ). MID-YEAR ENROLLMENT OR STATUS CHANGE. medflex Office of the State Comptroller CO-1306a (Rev. 10/2017) Healthcare Policy & Benefit Services Division Employee Name (last, first, middle initial) Employee Number Job Record Number EMPLOYEE INFORMATION. Street Address Date of Birth Social Security Number (must be provided). City, State, Zip Code Date of Hire / /. Employee Personal Email Office Telephone No. Home Telephone No. Gender Male Female Marital Status Single Married You CANNOT enroll in the medflex if you are: ELIGIBILITY. On unpaid leave for any reason Per Diem, sessional, durational, temporary or seasonal status Adjunct faculty or graduate assistant Former employees and rehired retirees Working or expected to work less than full time equivalent ( FTE). (Please check applicable event) Annual Election Amount $. ENROLLMENT INFORMATION. New Hire Return from leave Marriage (Annual minimum is $520 / Annual maximum is $2,650).

CO-1306a (Rev. 10/2017) Employee Name (last, first, middle initial) MEDICAL FLEXIBLE SPENDING PROGRAM (MEDFLEX) MID-YEAR ENROLLMENT OR STATUS CHANGE

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  Programs, Medical, Flexible, Spending, Medflex, Medical flexible spending program

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