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.

Enrollment/Change Form CBP

To enroll or report changes in your CBP.

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.

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.

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.)