Health Reimbursement Account Forms

Forms

• Reimbursement Account Claim Form
• You can now fill out this form online before you print. When entering information into the form, use tab to move between the fields. To complete your claim submission after printing the completed form, sign, attach supporting documentation and submit to SelectAccount.
• Direct Deposit Form
• Authorize an electronic transfer of your reimbursements from your reimbursement account to your checking or savings account. Note: this form can also be completed online.
• Medical Crossover Form
• Have your medical claims automatically submitted from your health plan to SelectAccount and avoid paperwork. Note: this form can also be completed online.
• Dental Crossover Form
• Have your dental claims automatically submitted from your dental plan to SelectAccount and avoid paperwork. Note: this form can also be completed online.
• Member Requested Authorization for Release of Information (ARI)
• Complete this form if you want SelectAccount to release information about you to someone else (for example: an agent or family member).
• Appeal Form
• Use this to provide additional information to have a denied claim reviewed.