Health Savings Account Document Archives | BRI

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Claim Form
- To request reimbursement of eligible expenses.
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.