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

Filling out the HCRA Direct Pay Enrollment Form is an important step for continued participation in the Health Care Reimbursement Account program. This guide will provide clear, step-by-step instructions to help you successfully complete the form online.

Follow the steps to accurately fill out the form.

1. Press the ‘Get Form’ button to access the HCRA Direct Pay Enrollment Form and open it for editing.
2. Begin by filling out your personal information in the designated fields. Start with your full name, including your first name, middle initial, and last name.
3. Input your Social Security Number in the appropriate field, followed by your campus information.
4. Complete your address fields, which should include your street address, city, state, and zip code.
5. Sign and date the form to verify the information you provided is complete and accurate.
6. Select the reason for your request by checking the appropriate box — either 'Separation from Employment' or 'Leave Without Pay'. Fill in additional details such as the termination date, effective date, and expected length of absence if applicable.
7. Indicate whether your leave is related to the Family Medical Leave Act (FMLA) by selecting 'Yes' or 'No'.
8. Specify your monthly contribution amount in the designated area.
9. If the applicant is not the employee, fill out their name, relationship to the employee, Social Security Number, and signature.
10. Review the Participation Rules to ensure understanding of eligibility and participation requirements.
11. After confirming all information is correct, save the changes to your form, and prepare to download, print, or share it as needed.

Take the next step by completing the HCRA Direct Pay Enrollment Form online today.