VEBA Plan Forms

For Account Holders

Brochures and Information Sheets

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.
  • 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.

Get Acrobat Reader

The forms on this site are in 'pdf' format and require a pdf reader, such as Acrobat Reader, to view them. Download Acrobat Reader for free.

Where to Submit Forms

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.

Login

Login to view your account status online.