Forms

Claim Form

Complete this form for reimbursement from your BESTflex Plan flexible spending account or EBC HRA.

COBRA Direct Payment Authorization

Complete this form to set up direct payment for COBRA premiums.

Direct Deposit Authorization

Complete this form to have your reimbursements deposited into your checking or savings account.

Letter of Medical Necessity

Submit this form when an otherwise ineligible incurred expense is used to treat a specific medical condition and is not personal in nature.

Participant Authorization

Complete this form to indicate individuals who are authorized to discuss protected details of your account.