Forms & Applications

Download. 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 medben@medben.com. Plan Administrators are welcome to contact their Account Representative.

In addition to the online services listed below, MedBen also offers customer-specific resources for EmployersMembersBrokers and Providers on their respective site pages.

Medical
Dental
Dental Employee Application – Apply or make coverage changes.
Dental AND Vision Employee Application  Apply for dental and/or vision coverage or make coverage changes.
Vision
Vision Employee Application – Apply or make coverage changes.
Vision AND Dental Employee Application  Apply for dental and/or vision coverage or make coverage changes.
FSA

Employee’s Guide to Flexible Spending Accounts (with Debit Card) – Overview/FAQ of MedBen FSAs for plan participants who use MedBen debit cards.

Employee’s Guide to Flexible Spending Accounts (No Debit Card) – Overview/FAQ of MedBen FSAs for plan participants who don’t use MedBen debit cards.

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.

Debit Card Substantiation Form – Substantiate purchases made with your MedBen Debit Card.

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

Request for Debit Card – Request a debit card for your dependent or replace a lost or stolen card.

Health Care FSA Examples of Qualified Medical Expenses – Examples of services and medical products that can be purchased with FSA funds.

Limited Purpose Health Care FSA Examples of Qualified Medical Expenses – Examples of dental and vision services and products that can be purchased with limited purpose FSA funds.

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.

FSA Reimbursement Request Form – Used when requesting reimbursement from a Health FSA plan, Limited Purpose FSA plan and/or Dependent Care reimbursement plan.

HRA

COBRA

HRA Reimbursement Request Form – Request reimbursement from your HRA account. NOTE: This form is generic and may not be specifically based on your employer’s HRA plan design.

HIPAA
Access to Personal Information Request Form – Request access to copy or inspect personal health information held by MedBen.
Request to Restrict Uses and Disclosures of Protected Health Information – Request restrictions of the use or disclosure of personal health information held by MedBen.
Accounting of Protected Health Information Request Form – Request an accounting of disclosures made by MedBen of your health and medical information.
Confidential Communication Request Form – Request alternate means of communication with MedBen.
PHI Amendment Request Form – Request MedBen to make corrections or amendments to your protected health information.
Privacy Complaint FormRegister a complaint if you believe anyone at MedBen has inappropriately used or disclosed protected health information.
Other
Disability Claim Form – Plan members can submit a claim for long-term or short-term disability benefits.
Transportation Reimbursement Form – Plan members can request reimbursement from their transportation compensation account.

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.

Death Claim Form (Life Insurance Claim) – Please contact MedBen Customer Service (800-686-8425 or medben@medben.com) to obtain a death claim form. Employers must complete and return this form (accompanied by a certified copy of the death certificate) in order for designated beneficiary to receive life insurance benefits.

Need more information about MedBen?