- 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.
- 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/Change Form HSA
- To enroll or make changes 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 (UMB)
- This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.
Looking for details on the COBRA Subsidy? Check out the Subsidy Resource page.
Contact Information
245 Kenneth Drive
Rochester NY 14623-4277
Benefit Resource, LLC
PO BOX 642
Willow Grove, PA 19090
EMPLOYEES: (800) 473-9595
EMPLOYERS: (866) 996-5200
For Employees
For Employers
Company
The Beniversal and eTRAC Prepaid Mastercards are issued by The Bancorp Bank pursuant to license by Mastercard International Incorporated. Mastercard is a registered
trademark, and the circles design is a trademark of, Mastercard International Incorporated. The Beniversal and eTRAC cards are accepted at qualified merchants accepting Debit
Mastercard. The Bancorp Bank; Member FDIC.
HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.
trademark, and the circles design is a trademark of, Mastercard International Incorporated. The Beniversal and eTRAC cards are accepted at qualified merchants accepting Debit
Mastercard. The Bancorp Bank; Member FDIC.
HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.