Forms

Flexible Spending Account (FSA) Forms

Health care or limited purpose flexible spending account claim form (HCFSA or LPFSA): If you have paid for eligible services or items out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.

Dependent care flexible spending account claim form (DCFSA, DCAP): If you have paid for eligible services or items out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.

Letter of Medical Necessity Form: Some items on the eligible expenses list require a doctor’s sign-off to verify that the medication or treatment that you are purchasing is medically necessary and thus, eligible to purchase with your FSA. Review the eligible expenses list to validate your expense. If it is listed as “LMN,” you will need your doctor to complete this form as part of your documentation.

LPFSA MyChoice Accounts HDHP Deductible Met Form: For Limited Purpose (dental + vision) FSAs, use this form to attest that you have met your health plan deductible and that your limited purpose FSA should be transitioned to a health care FSA for the remainder of the plan year.

Health Savings Account (HSA) Forms

UMB Beneficiary Designation Form: All HSAs participants should designate an account beneficiary. Complete this form and follow the instructions for submission to ensure your HSA beneficiary is set up.

UMB Trustee-to-Trustee Transfer of Assets Form: Complete and submit this form according to the instructions if you would like to transfer an HSA from another provider TO your MyChoice Accounts HSA.

UMB HSA Account Closure Form: Complete and submit this form according to the instructions if you would like to close your MyChoice Accounts HSA.

UMB HSA Contribution Form: Complete and submit this form according to the instructions if you would like to make a post-tax (non-payroll deduction) contribution to your HSA.

NOTE: UMB forms require your MyChoice Accounts HSA account number. To retrieve that:

  1. Log in to your benefits portal, navigate to Consumer Accounts and select ‘Account Statements’ under your Health Savings Account.
  2. Download the most recent account statement to view your UMB Account Number, located at the top left of page 1.
Health Reimbursement Arrangement (HRA) Forms

HRA Claim Form: If you have paid for eligible HRA expenses out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.

Commuter Benefits Forms

MyChoice Accounts Parking Claim Form: If you have paid for eligible commuter parking expenses out of pocket and need to get a reimbursement, you may file the claim directly in your benefits portal, in the MyChoice Mobile App or use this form.