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Spending Account Forms Employer Applications COBRA Continuation Election for Medical Reimbursement Accounts #H-8373  Health Reimbursement Account Employer Application including Flex Debit Card #H-8383 Health Reimbursement Account (HRA) Employer Application #H-8364  Health Savings Account Employer Application #H-83117  Premium Only Plan Application #M-53216  Reimbursement Account Flexible Benefits Employer Application including the Flex Debit Card #H-8381

Enrollment Forms

• Request for Reimbursement #H-8303  
• Request for Reimbursement (Spanish) #H-8371 
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory Combination #H-8754 
• Employee Reimbursement Account & Pre-Tax Premium Payment Mandatory with Debit Card Authorization #H-8772 
• Employee Reimbursement Account & Non-Mandatory Pre-Tax Premium Payment with Debit Card Authorization #H-8774 
• Health Reimbursement Account #H-8767 
• Health Reimbursement Account with Debit Card Authorization #H-8382 
• Health Savings Account Enrollment Form #H-83115 and #H-83116 

• Health Savings Account Application and Eligibility Form #H-83116 

• Pre-Tax Premium Payments and Employee Reimbursement Accounts Change Form #H-8764 
• Pre-Tax Premium Payments Mandatory Enrollment Form #H-8707 
• Pre-Tax Premium Payments Non-Mandatory #H-8711 

Administrative Forms for Employees

• View and download employee flex forms

Educational Materials

• Order Blue Priority Flex^SM member education materials on the Employer Toolkit