About Our Forms

You deserve fast answers, fast claims, and Web self-service. That's why we've created forms that provide the information you need, and are easy to use and understand.

If you need any assistance contact us 24/7/365 at 877.933.3539.

To view or print the PDF files, you'll need a free utility called Adobe Reader.

General Info


	What is a Cafeteria Plan?
	What is a MERP or HRA?
	What is COBRA?
	Get Free Acrobat Reader
	Contact Us

General Forms

		pdf
	HIPAA Authorization for Release
	Change of Address Mailing Address/Email Address Changes
	Change of Status Form C.O.S. Qualification Matrix www.changeofstatus.com
	Direct Deposit Authorization
	Fax Cover Sheet
	Leave of Absence Form
	Medical Necessity Letter
	Mileage Report
	Over-the-Counter Medical Guidelines
	Claim Form
	IIAS Merchant List Link

Health Savings Account (HSA)

		pdf
	HSA Additional Debit Card Request
	HSA Beneficiary Change/Spousal Consent
	HSA Death Distribution Request
	HSA Direct Deposit Enrollment/Change
	HSA Distribution Request
	HSA Contribution
	HSA Enrollment Form
	HSA Guide
	HSA Information Authorization
	HSA Information Change Notification
	HSA Power of Attorney Form