Flexible Spending Plan – PEHP

PEHP FLEXIBLE SPENDING FORMS
Flexible Spending
This claim form is for reimbursement of qualified medical expenses that have been paid out of pocket for the employee and/or family member on their plan.
Flexible Spending Reimbursement Claim Form (PDF)
Flexible Spending Salary
This form is used to communicate the amount to be deducted from an employee’s salary that will be contributed to a Flexible Spending Account for medical expenses for the Fiscal Year.
Flexible Spending Salary Authorization Form (PDF)

Dixie State University offers a Flexible Spending Plan through Public Employees Health Plan (PEHP). Complete benefit summary information and forms are available on the PEHP website. Access PEHP’s website at www.pehp.org.