Forms & Documents

HSA Trustee Transfer Form (BRI/Piermont)

This form is used to do a trustee-to-trustee transfer from an existing HSA to your new BRI HSA (powered by Piermont Bank/First Dollar).

HSA Direct Deposit Form (BRI/Piermont)

This form allows an employer, or other organization, to establish direct deposit into your BRI HSA (powered by Piermont Bank/First Dollar).

HRA/SRA Travel Attestation Form

COBRA Refund Request Form

Please use this form to authorize an ACH refund to your account.

Claim Form

To request reimbursement of eligible expenses.

PHI Authorization/Revocation Form

COBRA Brochure

Answers the many questions you may have regarding your COBRA benefits.

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 UMB Health Savings Account.

Transfer Form (UMB)

Form for transferring your account to UMB from another trustee

Beneficiary Form (UMB)

Designate the beneficiary for your UMB Health Savings Account.

Medical FSA Expense Worksheet

Extensive list of IRC section 125 eligible expenses to help you plan your Medical FSA election.