Claim Forms
Use these forms to submit a claim:

Medical Expense 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.

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 health care provider.

Appeal Form
Use this to provide additional information to have a denied claim reviewed.

Reimbursement Return Form
Use this form to return a payment to your account.

Election Forms
Complete these forms to sign up for optional features of your reimbursement account:

Direct Deposit Form
Sign in to authorize electronic transfer of your reimbursements from your HRA to your bank account.

Medical Crossover Form
For members with an account that includes the crossover feature, sign in to view or update your crossover election.

Dental Crossover Form
For members with an account that includes the crossover feature, sign in to view or update your crossover election.

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 a family member).

Link to Forms on the Blue Cross and Blue Shield of Kansas Website(www.bcbsks.com)

Please note that clicking on this link will direct you away from the SelectAccount website.