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Member COBRA Portal
Employer COBRA Portal
Forms and Reference Center
Please email completed forms to
Commuter- Enrollment/Change Form
Once completed, the enrollment forms must be submitted to your Human Resources department, NOT directly to Healthy Dollars.
Manual Claim Form
Dependent Care Account Claim Form
ICHRA/QSEHRA Claim Form
ACH- Direct Deposit Form
Letter of Medical Necessity
to upload files directly to Healthy Dollars!
ICHRA/QSEHRA- Enrollment Spreadsheet
FSA/DCA- Enrollment Spreadsheet
FSA,LPFSA,DCA- Enrollment Spreadsheet
To be completed by Employer. Once completed, the enrollment spreadsheets must be submitted directly to Healthy Dollars.
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