Plan Participant Information

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Healthcare and Dependent Care Accounts (FSA/DCA)

General Claim
Form

General Claim Form

Benefit Card
Request

Benefit Card Request

Employee Portal
Login Information

Employee Portal Login Info

FAQ – FSA
With Rollover

FAQ - FSA With Rollover

Limited Purpose
FSA

Limited Purpose FSA

Pay To Provider
Claim Form

Pay to Provider Claim Form

Demographic Update
Request

Demographic Update Request

Mobile App
Information

Mobile App Information

Overview With
FSA Grace Period

FSA Grace Period

Dependent Care
Information

Dependent Care Information

 Direct Deposit
Authorization

Direct Deposit Auth.

HIPAA
Authorization

HIPAA Authorization

Employee Portal
Guide

Employee Portal Guide

Eligible
Expense List

Eligible Expense List

Open Enrollment
Brochure

OE Brochure

Direct Deposit
Information

Direct Deposit Information

Letter of Medical
Necessity

Letter of Medical Necessity

Payment Card
Substantiation Information

Pymnt Card Substantiation Info.

Eligible Expense
Scanner

Eligible Expense Scanner

Transaction Dispute
Form

Transaction Dispute Form

Health Reimbursement Account (HRA)

General Claim
Form

General Claim Form

Benefit Card
Request

Benefit Card Request

Employee Portal
Login Information

Employee Portal Login Info

HRA Activation
Form

HRA Activation Form

Pay To Provider
Claim Form

Pay to Provider Claim Form

Demographic Update
Request

Demographic Update Request

Mobile App
Information

Mobile App Information

Transaction Dispute
Form

Transaction Dispute Form

 Direct Deposit
Authorization

Direct Deposit Authorization

HIPAA
Authorization

HIPAA Authorization

Employee
Portal Guide

Employee Portal Guide

Eligible Expenses List
HRA Unrestricted

Eligible Expenses Unrestricted

Direct Deposit
Information

Direct Deposit Information

Letter of Medical
Necessity

Letter of Medical Necessity

Payment Card
Substantiation Information

Payment Card Substantiation Info.

Health Savings Account (HSA)

Distribution
Request

Distribution Request

Letter of Medical
Necessity

Letter of Medical Necessity

 Eligible
Expense List

HSA Eligible Expense List

HSA & Limited FSA
 Fact Sheet

HSA & Limited FSA Fact Sheet

HSA Enrollment
 Form

HSA Enrollment Form

HSA Power of
Attorney

HSA Power of Attorney

Contribution
Request

Contribution Request

HSA Employee
Portal Guide

HSA Employee Portal Guide

HSA 
Overview

HSA Fact Sheet

Healthcare Bank
Custodial Agreement

Heathcare Bank Cust. Agreement

HIPAA
AUTHORIZATION

HIPPA Authroization

Information Update
Name Change

Info Update - Name Change

Transfer
Form

Transfer Form

Employee Portal
Login Information

Employee Portal Login

Health Savings
Account
FAQ

HSA FAQ

Healthcare Bank
HSA Disclosures

HC Bank HSA Disclosures

HSA Beneficiary
Change

HSA Beneficiary Change

Information
Update

Information Update

Direct Deposit
Authorization

Direct Deposit Auth.

Mobile App
Information

Mobile App Info

Five Benefits of
Health Savings Accounts

5 Benets of an HSA

Benefit Card
Request

Benefit Card Request

HSA PoA
Disability

PoA Disability

FAQ – HSA Form
5498- SA 2023

FAQ HSA Form 5498- SA 2023

Parking/Transit

Parking/Transit
Claim Form

Parking/Transit Claim Form

Benefit Card
Request Form

Benefit Card Request

Commuter Benefit
Brochure

Commuter Benefit Brochure

Employee Portal
Guide

Employee Portal Guide

Demographic Update
Request

Demographic Update Request

Employee Portal
Login Information

Employee Portal Login

Direct Deposit
Authorization 

Direct Deposit Authorization

Mobile App
Information

Mobile App Info

Direct Deposit
Information

Direct Deposit Information

COBRA

ACH Authorization
Form

ACH Authorization Form

COBRA Portal
Guide

COBRA Guide

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