Forms
To download a form, select the form name below.
Claim Forms
To request reimbursement for eligible expenses, complete the claim form for your plan below. Follow the instructions outlined on the form.
Direct Deposit Form
If you would like claims reimbursements to be directly deposited into your checking or savings account, complete the Direct Deposit Authorization Form below. Instructions on how to submit your authorization are included on the form.
Authorization for Direct Deposit Form
Medical Determination Form
Some expenses must be medically necessary in order to be eligible for reimbursement. Along with your claim, you must submit a Medical Determination Form completed by your health care provider. To learn if your expense requires this form, see eligible expenses.
Documents are in PDF format. You will need Adobe Reader to view and print these documents.
