Forms & Resources

Account Management Forms

• HSA Contribution Form
• HSA Beneficiary Designation Form
• HSA Trustee-to-Trustee Transfer Form
• HSA and Medicare
• Orthodontia Contract
  
• Letter of Medical Necessity
• Deductible Met Form
• Parking and Transit Attestation

Claim Forms - It’s always easiest and fastest to submit a claim online or on the mobile app. Use these forms when online and mobile are not available.

• Health Savings Account Claim Form
• Employee Reimbursement Account Claim Form
• Dependent Day Care Account Claim Form and Provider Certification
• Parking and Transportation Claim Form
• Unsubstantiated Claim – Business Debt Appeal Form

• Open Enrollment Brochure
• Health Savings Account Enrollment Brochure
• Employee Reimbursement Account Enrollment Brochure
• Commuter Account Enrollment Brochure
• Dependent Day Care Account Brochure
• Qualifying Life Events
• HSA/FSA Comparison Grid
• Direct Deposit Setup Guide – Get your reimbursements even faster by setting up direct deposit.
• Substantiation Requirements – Learn what’s needed for claim approval.
• Unsubstantiated Recovery Guide
  

• Employee Reimbursement Accounts Enrollment Form – Health Care Flexible Spending Accounts, Dependent Day Care Account, and Commuter Benefits Program
• Health Savings Account Active Employee Enrollment Form
• Health Savings Account Retiree Enrollment Form
  
• ETF Enrollment Terms for Health Savings Accounts
  
• ETF Enrollment Terms for Employee Reimbursement Accounts
  
• Late Enrollment Request Form
  
• Rescind Request for Pre-Tax Benefit Accounts
  
• Election Change Request Form