Forms & ApplicationsDownload. Print. Repeat as Needed.
On this page you will find some of MedBen’s most commonly used forms that you can download and print. If you have any questions about using and completing these forms, please contact MedBen Customer Service at 800-686-8425 or firstname.lastname@example.org. Plan Administrators are welcome to contact their Account Representative.
FSA Mileage Reimbursement Form – For claiming under your Health FSA the mileage used to obtain qualified medical services from a physician, hospital or facility to prevent or alleviate a physical disease, defect or illness.
Sample Letter of Medical Necessity – If a Letter of Medical Necessity is required from your provider to receive reimbursement from your FSA, this sample letter can be used for that purpose. Simply print out/save and give to your doctor.
Notice of Appeal/Designation of Authorization Form – Plan members wishing to file a formal appeal of a disputed claim should use this form. They can also designate another entity to file an appeal on their behalf.