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Get Medical Spending Conversion Form

PLAN YEAR 2012 ENROLLMENT/CHANGE FORM do not write in this box MEDICAL SPENDING CONVERSION MSC agency payroll code Premium Conversion PROGRAM 40 Rector Street 3rd Floor New York NY 10006-1705 212 306-7760 TTY 212 306-7629 nyc.gov/fsa Instructions q Open Enrollment September 26 - November 18 2011 effective January 1 2012 Complete Sections I II and IV. Enrollment Check one I. Please review the MSC Premium Conversion section in the Flexible Spending.

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