Forms & Reference Center
Please email completed forms to eligiblity@healthydollarsinc.com
Member Forms
This form is to be completed when submitting for reimbursement or direct provider payment. This form must also be accompanied by a detailed statement, itemized receipt, and/or explanation of benefits to ensure timely processing. You do not need to complete this form if you are submitting a claim via your online portal.
Complete this form in order to have reimbursement claims directly deposited into your checking or savings account. Once submitted, your information is saved to file so there is no need to send in this form each time.
This form needs to be completed by your doctor for items to be covered by you FSA funds which are normally considered ineligible. For example, vitamins, supplements, or massage services.
This form needs to be completed to receive reoccurring reimbursements for your eligible individual medical premiums.
This form is to be completed for daycare / preschool services that occur throughout the year that allow the parent/guardian the ability to work, interview for work or attend school in order to obtain work.
Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.
Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.
Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.
Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.
Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.
Employer Forms
To be completed by Employer
Once completed, the enrollment forms must be submitted directly to Healthy Dollars.