Member Forms

Frequently Used Forms

Difference Card Members

Difference Card Forms

• Difference Card Medical Reimbursement Form
• HIPAA Form

FSA Forms

• FSA Reimbursement Form (FSA, DCA, Transit/Parking)
• FSA Letter of Medical Necessity
• FSA Worksheet

HSA Forms

• HSA Transfer of Assets Form WealthCare Saver
• HSA Contribution Form WealthCare Saver (Rollover)
• Investing Your HSA Funds

Wellness Forms

• Wellness Program – Proof of Physical Exam
• Wellness Program – Proof of Physical Activity
• Wellness Program – Proof of Live Webinar Attendance