This page allows group members using such Specialty Services offerings as COBRA, HIPAA, flexible spending accounts (FSAs), health reimbursement arrangements (HRAs) and transportation compensation accounts to download frequently used forms.

Get Acrobat ReaderAll forms are saved in the .PDF format. To view and print a form requires Adobe Acrobat Reader. You can download a free copy of Reader by clicking here.

If you have any questions about what forms your group uses, contact the MedBen Customer Service Department at 800-686-8425 or medben@medben.com. For technical questions relating to downloading and printing of forms, e-mail this site's webmaster at chuckj@medben.com.

All forms measure 8½”x11” unless otherwise indicated. 
Forms open in a new browser window.

COBRA Forms
FORM 1001: COBRA Qualifying Event Form
This form notifies MedBen of a COBRA qualifying event.

 

HIPAA Forms

Access to Personal Information Request Form
Use this form to request access to copy or inspect personal health information held by MedBen.

Accounting of Protected Health Information Request Form
Use this form to request an accounting of disclosures made by MedBen of your health and medical information.

PHI Amendment Request Form
Use this form to request MedBen to make corrections or amendments to your protected health information.

Request to Restrict Uses and Disclosures of Protected Health Information
Use this form to request restrictions of the use or disclosure of personal health information held by MedBen.

Confidential Communication Request Form
Use this form to request alternate means of communication with MedBen.

Privacy Complaint Form
Use this form to register a complaint if you believe anyone at MedBen has inappropriately used or disclosed protected health information.

 

Flexible Spending Account (FSA) Forms

 

Per the Patient Protection and Affordable Care Act (PPACA), effective January 1, 2011, reimbursements for over-the-counter (OTC) medicines and drugs will no longer be eligible for reimbursement under a Health FSA Plan unless they are prescribed by a physician. The documents below provide information about this new regulation.

If you have any questions regarding the OTC change, please contact MedBen Customer Service at (800) 686-8425 or medben@medben.com.

FORM 1100: Compensation Redirection Agreement (NO Debit Card)
FORM 1100b: Compensation Redirection Agreement (WITH Debit Card)
Use one of these forms to participate in your company's FSA plan.

  • If your company does not offer the option of an FSA debit card, use Form 1100.

  • If your company does offer the option of an FSA debit card, use Form 1100b.

If reporting a change in status, Form 1101 must accompany Form 1100/1100b.

FORM 1101: Health and Dependent Care Change Request Form (8½”x14”)
Use this form to make a change in your flexible spending account (FSA) election or to change your address.

FORM 1102: Dependent Care Spending Reimbursement Request Form
Use this form to request reimbursement from the Dependent Care spending account of your FSA.

FORM 1103: Dependent Care Receipt for Services Form
A caregiver or provider of service can use this form as a receipt for dependent care services provided.

FORM 1105b: Debit Card Substantiation Form
Use this form to substantiate purchases made with your MedBen "Benny" Debit Card.

FORM 1107: Health Care Spending Reimbursement Request Form
Use this form to request reimbursement from your Health FSA account.

FORM 1109: Orthodontia Services Reimbursement Request Form
An orthodontist (or authorized bookkeeper) can use this form to request reimbursement for services.

FORM 1114: Request for Debit Card
Use this form to receive a debit card for your dependent or replace a lost or stolen card.

FORM 1131: Examples of Qualified Medical Expenses
This form provides a useful overview of medical expenses that typically qualify for reimbursement under a Health FSA account. You can also find a more detailed list on our IRS-eligible Expenses page.

 

Health Reimbursement Arrangement (HRA) Forms
FORM 1108: HRA Reimbursement Request Form
Use this form to request reimbursement from your HRA account. NOTE: This form is generic and may not be specifically based on your employer's HRA plan design.

 

Transportation Compensation Forms

FORM 1115: Transportation Reimbursement Form
Use this form to request reimbursement from your transportation compensation account.

FORM 1116a: Transportation Compensation Redirection Agreement
Use this form to participate in your company's transportation compensation plan.

 

 MedBen Mutual Forms • MedBen Administrators Forms
MedBen Specialty Services Forms • MedBen Dental and VisionPlus Forms