Form 3938-OHIO-HC "Spending Account Enrollment Form" - Ohio

What Is Form 3938-OHIO-HC?

This is a legal form that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2019;
  • The latest edition provided by the Ohio Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 3938-OHIO-HC by clicking the link below or browse more documents and templates provided by the Ohio Department of Administrative Services.

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Download Form 3938-OHIO-HC "Spending Account Enrollment Form" - Ohio

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2020 State of Ohio
SPENDING ACCOUNT ENROLLMENT FORM
You must complete this form if you wish to start a tax-free
HEALTH CARE
Health Care Spending Account.
For Open Enrollment Only: You may enroll online at www.wageworks.com
Name (Please Print) Last
First
MI
State of Ohio User ID #
Home Address Street
City
State
ZIP
Daytime Phone
Home Phone
Date of Hire
Date of Birth
(
)
(
)
E-mail Address
ENROLLMENT STATUS:
OPEN ENROLLMENT
RE-ENROLLMENT
NEW HIRE
CHANGE IN STATUS *
PROBATIONARY END DATE: __________
CHANGE TYPE: ______________________________________________
DATE: _______ / _______ / _______
* Appropriate supporting documentation must be submitted with this form.
• Indicate the amount you wish to contribute through tax-free salary deduction by completing the section below.
.
• For assistance, complete the Health Care Spending Account worksheets available at das.ohio.gov/flexiblespendingaccounts
• If you have questions, consult your Flexible Spending Accounts Reference Guide, or call Customer Service at 1-855-428-0446.
• Your effective date will be the first of the month after WageWorks approves your enrollment or January 1, 2020 if completed during open enrollment.
To be eligible, you must be a permanent full-time or permanent part-time employee who has successfully completed your initial probationary period (if applicable).
Enrollment must occur within 31 days of eligibility or during the open enrollment period.
The Benefit Year is January through December
HEALTH CARE SPENDING ACCOUNT
Use your Health Care Spending Account for eligible uninsured, out-of-pocket medical expenses incurred by you, your family members or both.
(Annual allowable minimum contribution per participant is $240. The maximum contribution per participant is $2,500.)
Total ANNUAL ELECTION amount $ _____________________________________
Deductions will be taken the first 24 pay periods of the calendar year unless you are paid monthly.
For mid-year enrollment, your election amount will be divided among the remaining of the first 24 calendar year pay periods.
LIMITED PURPOSE SPENDING ACCOUNT
Elect only if you are enrolled in or planning to enroll in a High Deductible Health Plan (HDHP) and contributing to a Health Savings Account (HSA).
This account covers dental and vision expenses only. (Annual allowable minimum contribution per participant is $240. The maximum contribution per participant is $2,500.)
Total ANNUAL ELECTION amount $ _____________________________________
Deductions will be taken the first 24 pay periods of the calendar year unless you are paid monthly.
For mid-year enrollment, your election amount will be divided among the remaining of the first 24 calendar year pay periods.
IMPORTANT
• I hereby authorize my employer to reduce my gross salary before
• I understand and agree that my employer and WageWorks, the contract
Medicare, local, state, and federal income taxes are calculated by the total
administrator, will not incur any liability resulting from either my
amount of annual salary deduction indicated above.
participation in any Spending Account or my failure to sign or accurately
• I understand that the funds in one Spending Account cannot be used to
complete this Enrollment Form. I further understand that if I elect not to
reimburse expenses covered by another Spending Account.
participate in salary deduction with respect to the benefits listed above, I
• I understand that expenses for which I am reimbursed cannot be
hereby forego my right to participate during the upcoming calendar year,
unless otherwise provided by law.
deducted on my income tax return.
• I understand the amount of salary deduction will include the items
• I certify that: 1) I will only use my Spending Account to pay for IRS-
specified above and will continue in effect unless I terminate employment
qualified expenses and only for my IRS-eligible dependents, 2) I will
before the end of the calendar year or file an approved Change In Status
exhaust all other sources of reimbursement, including those provided
Election Form with the contract administrator within 31 days of the event.
under my employer’s plan(s) before seeking reimbursement from
• I understand that the funds in any Spending Account can only be paid out
my Spending Account, 3) I will not seek reimbursement through
to reimburse payment of eligible expenses actually incurred during my
any additional source, and 4) I will collect and maintain sufficient
period of coverage.
documentation to validate the foregoing.
By signing this form you certify that you expect to receive payroll deductions to support your annual election amount.
EMPLOYEE SIGNATURE
DATE SIGNED
SUBMIT YOUR COMPLETED FORM TO P.O. BOX 14766, LEXINGTON KY 40512-4766 OR FAX TO 1-866-672-4780.
© 2015-2019 WageWorks, Inc. All rights reserved. WageWorks® is a registered service mark of WageWorks, Inc. Throughout this document, “savings” refers only to tax savings. No
part of this document constitutes tax, financial or legal advice. Please consult your advisor regarding your personal situation and whether this is the right program for you.
3938-OHIO-HC (201908)
2020 State of Ohio
SPENDING ACCOUNT ENROLLMENT FORM
You must complete this form if you wish to start a tax-free
HEALTH CARE
Health Care Spending Account.
For Open Enrollment Only: You may enroll online at www.wageworks.com
Name (Please Print) Last
First
MI
State of Ohio User ID #
Home Address Street
City
State
ZIP
Daytime Phone
Home Phone
Date of Hire
Date of Birth
(
)
(
)
E-mail Address
ENROLLMENT STATUS:
OPEN ENROLLMENT
RE-ENROLLMENT
NEW HIRE
CHANGE IN STATUS *
PROBATIONARY END DATE: __________
CHANGE TYPE: ______________________________________________
DATE: _______ / _______ / _______
* Appropriate supporting documentation must be submitted with this form.
• Indicate the amount you wish to contribute through tax-free salary deduction by completing the section below.
.
• For assistance, complete the Health Care Spending Account worksheets available at das.ohio.gov/flexiblespendingaccounts
• If you have questions, consult your Flexible Spending Accounts Reference Guide, or call Customer Service at 1-855-428-0446.
• Your effective date will be the first of the month after WageWorks approves your enrollment or January 1, 2020 if completed during open enrollment.
To be eligible, you must be a permanent full-time or permanent part-time employee who has successfully completed your initial probationary period (if applicable).
Enrollment must occur within 31 days of eligibility or during the open enrollment period.
The Benefit Year is January through December
HEALTH CARE SPENDING ACCOUNT
Use your Health Care Spending Account for eligible uninsured, out-of-pocket medical expenses incurred by you, your family members or both.
(Annual allowable minimum contribution per participant is $240. The maximum contribution per participant is $2,500.)
Total ANNUAL ELECTION amount $ _____________________________________
Deductions will be taken the first 24 pay periods of the calendar year unless you are paid monthly.
For mid-year enrollment, your election amount will be divided among the remaining of the first 24 calendar year pay periods.
LIMITED PURPOSE SPENDING ACCOUNT
Elect only if you are enrolled in or planning to enroll in a High Deductible Health Plan (HDHP) and contributing to a Health Savings Account (HSA).
This account covers dental and vision expenses only. (Annual allowable minimum contribution per participant is $240. The maximum contribution per participant is $2,500.)
Total ANNUAL ELECTION amount $ _____________________________________
Deductions will be taken the first 24 pay periods of the calendar year unless you are paid monthly.
For mid-year enrollment, your election amount will be divided among the remaining of the first 24 calendar year pay periods.
IMPORTANT
• I hereby authorize my employer to reduce my gross salary before
• I understand and agree that my employer and WageWorks, the contract
Medicare, local, state, and federal income taxes are calculated by the total
administrator, will not incur any liability resulting from either my
amount of annual salary deduction indicated above.
participation in any Spending Account or my failure to sign or accurately
• I understand that the funds in one Spending Account cannot be used to
complete this Enrollment Form. I further understand that if I elect not to
reimburse expenses covered by another Spending Account.
participate in salary deduction with respect to the benefits listed above, I
• I understand that expenses for which I am reimbursed cannot be
hereby forego my right to participate during the upcoming calendar year,
unless otherwise provided by law.
deducted on my income tax return.
• I understand the amount of salary deduction will include the items
• I certify that: 1) I will only use my Spending Account to pay for IRS-
specified above and will continue in effect unless I terminate employment
qualified expenses and only for my IRS-eligible dependents, 2) I will
before the end of the calendar year or file an approved Change In Status
exhaust all other sources of reimbursement, including those provided
Election Form with the contract administrator within 31 days of the event.
under my employer’s plan(s) before seeking reimbursement from
• I understand that the funds in any Spending Account can only be paid out
my Spending Account, 3) I will not seek reimbursement through
to reimburse payment of eligible expenses actually incurred during my
any additional source, and 4) I will collect and maintain sufficient
period of coverage.
documentation to validate the foregoing.
By signing this form you certify that you expect to receive payroll deductions to support your annual election amount.
EMPLOYEE SIGNATURE
DATE SIGNED
SUBMIT YOUR COMPLETED FORM TO P.O. BOX 14766, LEXINGTON KY 40512-4766 OR FAX TO 1-866-672-4780.
© 2015-2019 WageWorks, Inc. All rights reserved. WageWorks® is a registered service mark of WageWorks, Inc. Throughout this document, “savings” refers only to tax savings. No
part of this document constitutes tax, financial or legal advice. Please consult your advisor regarding your personal situation and whether this is the right program for you.
3938-OHIO-HC (201908)