COBRA
- COBRA Brochure
- Answers the many questions you may have regarding your COBRA benefits.
- HIPAA Privacy Release Form
- Authorization for Use or Disclosure of Health Information.
Commuter Benefit Plan
- Enrollment Form CBP
- To enroll in your CBP.
- Claim Form CBP
- To request reimbursement for eligible workplace commuting expenses.
- Change Form CBP
- To report changes in status, address, elections, etc. for 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
- Authorization for Use or Disclosure of PHI
- 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 Form FSA
- To enroll in your FSA Plan.
- 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.
- Change Form FSA
- To report changes in status, address, elections, etc. for your FSA Plan.
- 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.
- Claim Form
- To request reimbursement of eligible HRA and FSA expenses.
- Certification of Medical Necessity Form
- To use for medical services/items that require additional documentation from a licensed health care provider.
Health Reimbursement Account
- Authorization for Use or Disclosure of PHI
- 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
- 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.
- Claim Form
- To request reimbursement of eligible HRA and FSA expenses.
- 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
- Request a withdrawal from your UMB Health Savings Account
- Name Change Form
- Form to change the name associated with your Health Savings Account.
- Transfer Form
- Form for transferring your account to UMB from another trustee
- Beneficiary Form
- 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 Form HSA
- To enroll 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
- This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.
- Change Form HSA
- To facilitate a new HSA payroll deduction or change an existing HSA payroll deduction after the HSA is open and established. This form should be used to update your name, email address, telephone number, etc. to Benefit Resource. If an account is not open, please use the HSA Enrollment Form.
