Flex Spending Account enrollment and calculation

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Flexible Spending Account
 Deduction Worksheet
 This worksheet will help you calculate your applicable expenses and how
 much money would be in an FSA deduction each pay period.

 Medical/Dental/Vision Reimbursement Account
  Annual Medical Expenses, such as:
  Deductibles and co-pays             $ _____________
  Routine physical exams              $ ___________60
  Prescriptions                       $ ___________96
  Flu shot                            $ _____________
  Chiropractic care                   $ _____________
  Gastroenterologist                  $ _____________
  Podiatrist                          $ _____________
  Ophthamologist                      $ __________180
  Audiologist                         $ ___________60
  Hearing Aids                        $ __________100
  Other                               $ _____________
 Annual Dental Expenses, such as:
  Deductibles and co-pays             $ _____________
  Routine check-ups                   $ _____________
  Orthodontia                         $ _____________
  Other                               $ _____________
 Annual Vision Care Expenses, such as:
  Exams                               $ ___________60
  Eyeglasses                          $ __________180
  Contact lenses, solutions, cleaners $ _____________
  Other                               $ _____________
 Rolled Over from Last Year           $ __________450
 Total Estimated                      $ __________286