Forms & Documents

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 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.

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.