Documents and Forms

Please find online account instructions and frequently asked questions below for your convenience.

Once you have completed any of the claim forms listed below, you may either upload them at your online portal along with any substantiation or email it all to service@healthydollarsinc.com for processing.

  • Manual Claim Form - To be completed when submitting for reimbursement or direct to provider payment. Must be accompanied by a detailed statement and/or explanation of benefits when applicable. 
     

  • Dependent Care Account Claim Form - Complete for daycare services that occur throughout the year (daycare, preschool).

Any of the forms listed below can be completed and emailed to service@healthydollarsinc.com for processing.

  • Letter of Medical Necessity Form - Please have this form completed by your doctor for items that you need to be covered by you FSA or HSA funds which are normally considered ineligible.
     

  • ACH Form (Direct Deposit) - Complete this form in order to have claim reimbursements directly deposited into your checking or savings account.


The enrollment forms must be completed and submitted to your Human Resource department.