Transportation Reimbursement Account Forms

Forms

Transportation Program Claim Form
Submit a claim to SelectAccount.
Direct Deposit Form
Authorize an electronic transfer of your reimbursement from your reimbursement account to your bank account. 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.

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Please send completed forms to:

SelectAccount

PO Box 64193

St. Paul, MN 55164-0193

Fax: (651) 662-7247 or (866) 231-0214

If you have questions about our products or how to complete a form, please contact us.