VEBA Plan Forms

Brochures and Information Sheets

• Medical Expense Reimbursement Guide
• Learn the general guidelines about eligible and ineligible expenses.
• Over-the-Counter Drugs Reimbursement Guidelines
• Find out which over-the-counter drugs are eligible for reimbursement from your VEBA account.
• VEBA Enrollment Brochure
• The VEBA plan gives you support for and control over your health decisions.
• Guide to Understanding Crossover
• Find out about SelectAccount's Crossover feature and its advantages.
• VEBA Investment Brochure
• Understand the investment options your VEBA account offers.

Forms

• Reimbursement Account Claim Form
• Submit a claim to SelectAccount.
• Letter of Medical Necessity
• In order to determine eligibility for Potentially Eligible Expenses, you will need to obtain a Letter of Medical Necessity from your healthcare provider.
• 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.
• Account Access Form
• Designate whether you would like your VEBA account accessed for any claims processed by SelectAccount.
• 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.