INSTRUCTIONS: ALABAMA FLEXIBLE SPENDING ACCOUNT STATUS CHANGE (Form PEEHIP FSA Change)

To document a change in your status as an Alabama public employee enrolled in a flexible spending account administered by BlueCross BlueShield, use a PEEHIP FSA change form. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 1: The first section concerns the subscriber. In the first four blank boxes, enter your Social Security number or PID number, first name, middle name or initial and last name.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 2: In the next four blank boxes, enter your mailing street address, city, state and zip code.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 3: In the next blank box, enter your date of birth.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 4: In the next two blank boxes, enter your home and work phone numbers.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 5: In the next blank box, enter your email address.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 6: Indicate whether you are single, married, divorced, legally separated or widowed with a check mark.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 7: The next reason concerns your reason for the status change. Indicate this with a check mark next to the applicable statement.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 8: Enter the date on which the qualifying event occurred.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 9: The next section concerns your flexible spending account. If making a new annual election amount, check the box where indicated. Enter the monthly and annual amounts.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 10: Check the second box if you wish to stop payroll deductions.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 11: The next section concerns dependant care flexible spending accounts. Indicate with a check mark if you wish to make a new annual election amount or to stop payroll deductions.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 12: Sign and date the form where indicated.