SCSC > Insurance and Related Information > VEBA/HRA/HSA Plans > Forms

Contacts:
Larry IntVeld, Cell 651-226-4365, Fax 651-483-2598
Lisa Litke, Ph. 507-389-6999, Fax 507-389-1772
Les Martisko, Ph.D. Ph. 507-389-1881, Fax 507-389-1772

THE VEBA/HRA/HSA PLANS

FORMS

• Reimbursement Account Claim Form (PDF)
  Submit a claim to SelectAccount.

• Letter of Medical Necessity (PDF)
  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 (PDF)
  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 (PDF)
  Have your medical claims automatically submitted from your health plan to SelectAccount and avoid paperwork. Note: this form can also be completed online.

• Account Access Form (PDF)
  Designate whether you would like your VEBA account accessed for any claims processed by SelectAccount.

• Member Requested Authorization for Release of Information (ARI) (PDF)
  Complete this form if you want SelectAccount to release information about you to someone else (for example: an agent or family member).

• Appeal Form (PDF)
  Use this to provide additional information to have a denied claim reviewed.

• Adoption Agreement for the MSC VEBA Plan (Microsoft Word doc or PDF)
  

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Page modified: 1/22/10