BRI | Benefit Resource

  • Participants
  • Employers
  • Home
  • Blog
  • Forms
  • Espaňol
  • Contact
  • COVID-19
    • Participants
    • Employers
    • COBRA
  • Participants
    • Flexible Spending Account
      • Using your FSA
      • Questions?
    • Commuter Benefits Plan (CBP)
      • Using Your CBP
      • Questions?
      • CBP Limits
    • Health Savings Account (HSA)
      • Using Your HSA
      • Questions?
      • HSA Limits
    • Health Reimbursement Account (HRA)
      • Using Your HRA
      • Questions?
    • Resources
  • Employers
    • Plans & Services
    • Why BRI?
    • Resources
  • Consultants
    • Plans & Services
    • Why BRI?
    • Resources
  • Contact Benefit Resource
  • Blog
  • COVID-19 Resources
  • About Benefit Resource
    • Leadership
    • Careers
    • Partnerships
    • Resource Center
  • Participants
    • Login
    • Commuter Benefit Plan
      • CBP Basics
      • Using Your CBP
      • Questions?
      • CBP Limits
      • Commuter Resources
      • Commuter Resource Center
    • Flexible Spending Account
      • FSA Basics
      • Using your FSA
      • Questions?
      • FSA Resources
    • Health Savings Account
      • HSA Basics
      • Using Your HSA
      • Questions?
      • HSA Limits
      • HSA Resources
    • Health Reimbursement Account
      • HRA Basics
      • Using Your HRA
      • Questions?
      • HRA Resources
    • COBRA
      • COBRA Login
    • Resources
      • All Resources
      • BRiWeb
      • BRiMobile
      • BRiAlerts
      • Beniversal Card
      • ID Theft Services
  • Employers
    • Request A Quote
    • Plans & Services
      • Commuter Benefit Plans
      • Flexible Spending Account
      • Health Savings Account
      • Health Reimbursement Account
      • COBRA Administration
      • Direct Billing
      • Specialty Accounts
    • Resources
      • All Resources
      • Open Enrollment
      • BRI Insights
      • BRiWeb Employer Portal
      • OE Email Request
    • Why BRI?
  • Consultants
    • Request A Quote
    • Plans & Services
      • Commuter Benefit Plans
      • Flexible Spending Account
      • Health Savings Account
      • Health Reimbursement Account
      • COBRA Administration
      • Direct Billing
      • Specialty Accounts
  • FAQs
  • Resources
    • Participant Resources
      • All Resources
      • Open Enrollment
      • Commuter Resource Center
    • Employer Resources
      • All Resources
      • Open Enrollment
      • OE Email Request
  • About
    • Contact Benefit Resource
    • Partnerships
    • Recognition
    • Leadership
    • News
    • Resource Center
    • Careers
Forms/Health Savings Account
If you have a login, you don’t need to download forms.

Get things done faster online.

  • 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/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
    • This form can be used to update your name, email address, telephone number, and home address information for your HSA to UMB Financial Corporation.

Benefit Resource, LLC

Simplifying the complexity of benefits for maximum savings and peace of mind.

Contact Information

245 Kenneth Drive
Rochester NY 14623-4277

email: info@benefitresource.com

phone: (866) 996-5200

fax: (585) 424-7273

Participant Links

  • Commuter Benefit Plan
  • Flexible Spending Account
  • Health Savings Account
  • Health Reimbursement Account
  • Resources

Employer Links

  • Why BRI
  • Plans & Services
  • Resources

Consultant Links

  • Why BRI
  • Plans & Services

Connect With Us

  • Facebook
  • Twitter
  • LinkedIn

Search this Site

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.

©2021 BRI | Benefit Resource All Rights Reserved.Privacy Policy|Terms of Use