Health Care / Dependent Care Reimbursement Account (HCRA/DCRA) Enrollment Form

The HCRA/DCRA Enrollment Form allows a new or existing employee to enroll or make changes to their HCRA and/or DCRA account.

Applicant Instructions

1. After launching the HCRA/DCRA Enrollment Form, an Adobe Sign Form will prompt you for your name and email.
2. Complete all required fields
3. The following information is needed to complete the HCRA-DCRA Enrollment Form
   • Employee Information: Name, SSN, and marital status.