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Forms & Documents

General

How to File a Complaint

Change of Personal Information Form

Member Reimbursement Form

Authorization to Negotiate & Access Medical Bills

Return Mistaken Contribution Form

Member Electric Transfer of Funds Form

Medical Questionnaire

HSA & Investments

Distribution Excess HSA Contribution Form

HSA Letter of Medical Necessity

HSA Partial Transfer Form

HSA Closure Request Form

HSA Rollover Request Form

HSA Transfer Form

Instructions Upon Divorce

Mistaken HSA Distribution Form

HSA Instruction Upon Death

HSA Contribution Form

HSA Letter of Medical Necessity

HSA Reimbursement Form

HSA Transfer Form (Spanish)

Legal & Policy

Member Rights and Responsibilities

Request Accounting PHI Disclosures Form

Request to Amend PHI

Authorization to Disclose PHI

Official Accident Form

Official Disability Form

Policy

Privacy Notice Simplified

Privacy Notice

Beneficiary Designation Form

Affidavit of Next of Kin

CCPA Privacy Notice

HIPAA Notice

PHI Restriction Request Form

Immediate Family Member Treatment Form

Privacy Policy

Request Access PHI Form

Request Access PHI Form (Spanish)