Forms
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COBRA
- COBRA Refund Request Form
- Please use this form to authorize an ACH refund to your account.
- PHI Authorization/Revocation Form
- COBRA Brochure
- Answers the many questions you may have regarding your COBRA benefits.
Commuter Benefit Plan
- Claim Form
- To request reimbursement of eligible expenses.
- Enrollment/Change Form CBP
- To enroll or report changes in your CBP.
- Direct Deposit Authorization Form
- To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
Flexible Spending Account
- Claim Form
- To request reimbursement of eligible expenses.
- PHI Authorization/Revocation Form
- Medical FSA Expense Worksheet
- Extensive list of IRC section 125 eligible expenses to help you plan your Medical FSA election.
- Opt Out Form FSA
- To decline participation in the tax-free benefit.
- Enrollment/Change Form FSA
- To enroll in your FSA Plan or to report changes in status, address, elections, etc.
- Dependent Care Receipt
- For your dependent care provider to use as a receipt for eligible dependent care services provided to you.
- Dependent Care Expense Worksheet
- Extensive list of IRC section 125 eligible expenses to help you plan your Dependent Care FSA election.
- Over-The-Counter (OTC) Chart
- Sample chart of OTC items that may be eligible from your HRA or FSA. You should check your plan’s documentation to see if OTC items are eligible under your plan.
- Mileage Expense Certification Form
- To provide supporting documentation when claiming mileage for eligible services from your pre-tax account.
- Direct Deposit Authorization Form
- To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
- Certification of Medical Necessity Form
- To use for medical services/items that require additional documentation from a licensed health care provider.
Health Reimbursement Account
- HRA Recurring Premium Attestation Form
- Claim Form
- To request reimbursement of eligible expenses.
- PHI Authorization/Revocation Form
- Over-The-Counter (OTC) Chart
- Sample chart of OTC items that may be eligible from your HRA or FSA. You should check your plan’s documentation to see if OTC items are eligible under your plan.
- Opt Out Form
- To opt out of participating in your employer sponsored HRA.
- Mileage Expense Certification Form
- To provide supporting documentation when claiming mileage for eligible services from your pre-tax account.
- Medical Expense Worksheet
- Extensive list of medical expenses that may be eligible under your HRA Plan.
- Enrollment/Change Form HRA
- To enroll or report changes in your HRA Plan.
- Direct Deposit Authorization Form
- To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
- Certification of Medical Necessity Form
- To use for medical services/items that require additional documentation from a licensed health care provider.
Health Savings Account
- Withdrawal Request Form (UMB)
- Request a withdrawal from your UMB Health Savings Account
- Name Change Form (UMB)
- Form to change the name associated with your Health Savings Account.
- Transfer Form (UMB)
- Form for transferring your account to UMB from another trustee
- Beneficiary Form (UMB)
- Designate the beneficiary for your Health Savings Account.
- Over-The-Counter (OTC) Chart
- Sample chart of OTC items that may be eligible from your HSA.
- Medical Necessity Directive Form HSA
- To use for personal documentation of medical services/items, such as over-the-counter medicines and drugs, that require additional documentation from a licensed health care provider. (Retain for your records.)
- Enrollment/Change Form HSA
- To enroll or make changes in your HSA program.
- Direct Deposit Form
- This form allows an employer, or other organization, to establish direct deposit into your HSA.
- Change of Contact Information (UMB)
- This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.
