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  • Hcra Direct Pay Enrollment Form - The California State University - Calstate

Get Hcra Direct Pay Enrollment Form - The California State University - Calstate

Efits Representative (Last) Social Security Number Campus Employee Name (First) (MI) Address City Signature State Zip Date Reason for Request (check one) Separation from Employment Leave Without Pay Termination Date Effective Date Expected Length Is this a FMLA leave? Yes No Monthly Contribution Amount $ Complete this section if applicant is not the employee Name of Applicant Relationship to Employee Signature Social Security Number.

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An HCRA is an employee benefit provided by the Judiciary that allows you to save money. With an HCRA, you set a specific amount of pre-tax dollars to be withheld from your paycheck. You can then use those funds to pay for qualified health care expenses, including medical, dental and vision expenses.

A HCRA allows you to set aside a portion of your pay on a pre-tax basis to reimburse yourself for eligible health, dental and vision care expenses for you, your spouse or registered domestic partner and eligible dependents.

The Health Care Reimbursement Account (HCRA) lets you set aside part of your paycheck on a pre-tax basis that you can then use to pay certain health care expenses for you, your spouse and dependents incur throughout the year.

The CSU Dependent Care Reimbursement Account (DCRA) provides reimbursement for eligible dependent care expenses from your pretax income, via a special tax-free account set up for this purpose. Each month, the dollar amount you preselect is deducted from your salary before federal, state and FICA taxes are withheld.

You will be notified of the limit on your Health Care Reimbursement Account contributions, if any apply. Your payroll deductions are exempt from federal, state and FICA taxes. However, they are not exempt from CalPERS retirement contributions.

With an HCRA, you set a specific amount of pre-tax dollars to be withheld from your paycheck. You can then use those funds to pay for qualified health care expenses, including medical, dental and vision expenses. Without your HCRA you would pay for those expenses with money that's already been taxed.

A Health Care Reimbursement Account (HCRA) allows you to use pre-tax dollars to pay for eligible out-of-pocket health care expenses, saving you up to 35% in taxes. Use the funds to pay for a broad range of expenses for you, your spouse and your tax dependents – even if they aren't covered by your health plan.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232