Flexible Spending Account (Fsa) Autopay Waive Form
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1Flexible Spending Account (FSA) AutoPay Waive Form for
Sandia employees enrolled in Sandia Total Health
administered by Blue Cross and Blue Shield of New Mexico
Employee Name: _________________________________________________________________________
Employee Address: ________________________________________________________________________
Employee Social Security Number (last 4 digits only): __________________________________________
Plan Year: __________
If you are enrolled in Sandia Total Health administered by Blue Cross and Blue Shield of New Mexico
and the Dental Care Program through Sandia, claims data will be sent to PayFlex for automatic
reimbursement of eligible FSA expenses. This is called AutoPay. If you would like to turn off this
AutoPay feature, check the appropriate box below.
Waiver of AutoPay
[ ] Cancel the AutoPay feature for Sandia Total Health BCBSNM medical claims.
[ ] Cancel the AutoPay feature for the Dental Care Program dental claims.
This agreement is subject to the terms of the employer’s Cafeteria Plan, as amended from time to time
in effect, shall be governed by and construed in accordance with applicable laws, shall take effect as a
sealed instrument under applicable laws, and revokes any prior election and compensation redirection
agreement relating to such plan.
__________________________________________________________
___________________________
Employee’s Signature
Date
Please return this form to:
PayFlex Systems USA
ATTN: Eligibility Department
10822 Farnam Drive
Omaha, NE 68154
or
Fax to: 402-231-4283
Blue Cross and Blue Shield of New Mexico is a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
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