Employee Forms

Spending Account Forms:

Claim Form

Employee Request for Service Form

Direct Deposit Form

Provider's Letter of Medical Necessity

Substantiation Request Form

HRA Activation Form

FSA Worksheet

HSA Enrollment Form

All Other HSA Forms (Directs to Website of our HSA banking partner, The Bancorp Bank)

COBRA Forms:

COBRA Request for Service Form

COBRA Participant Recurring ACH Form

COBRA Open Enrollment Form

Spanish Forms/Formas en Espanol:

Claim Form/Forma de Reclamo

Substantiation Request/Solicitud de Comprobacion

How to Use Your Card/Como Utilizar Su Tarjeta