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Member COBRA Portal

Employer Portal

Employer COBRA Portal

Forms and Reference Center

Please email completed forms to eligiblity@healthydollarsinc.com.

Enrollment Forms

HRA-Enrollment/Change Form

FSA-Enrollment/Change Form

DCA-Enrollment/Change Form

Commuter- Enrollment/Change Form

HSA-Enrollment/Change Form

Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.

Member Forms

Manual Claim Form

Dependent Care Account Claim Form

ICHRA/QSEHRA Claim Form

ACH- Direct Deposit Form

Letter of Medical Necessity

Employer Forms

Use this SECURE LINK to upload files directly to Healthy Dollars!

ICHRA/QSEHRA- Enrollment Spreadsheet

FSA/DCA- Enrollment Spreadsheet

FSA,LPFSA,DCA- Enrollment Spreadsheet

HRA-Enrollment Spreadsheet

To be completed by Employer. Once completed, the enrollment spreadsheets must be submitted directly to Healthy Dollars.

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