Employers - Consultants

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Employer/Consultant Forms

FSA

HSA

HRA

  • 90% Rule Merchant List
    This is a list of merchants that have registered with SIGIS as meeting the IRS 90% Rule which requires that at least 90% of gross sales are from prescriptions/Rx or qualified over-the-counter health care products. Meeting this rule means that the debit card may be used at this location. You will still be required to submit substantiation for purchases made at merchants meeting the 90% rule and who do not have IIAS.
  • Additional Debit Card Request
    Complete this form to request an additional card for a spouse or dependents over the age of 18.
  • Authorized Representative Request (HIPAA)
    Complete this form to communicate authorization to DBI to release information on your FSA, HSA, or HRA to another individual.
  • Automatic Orthodontia Request
    Use this form to request automatic reimbursement of your orthodontia expense from your health care reimbursement account. This form must be completed and signed by both you and your orthodontist.
  • Consumer Portal Guide for Direct Deposit
  • Consumer Portal Guide to Order Additional Debit Cards
  • Consumer Portal Login Instructions
  • Debit Card Substantiation Form
    Use this form only for submitting debit card substantiation when requested by Discovery Benefits. Requests for reimbursement of out-of-pocket expenses need to be submitted on a Reimbursement Request Form.
  • Direct Deposit Form
    Complete this form to provide Discovery Benefits with your bank account information for the direct deposit of reimbursement and distribution requests.
  • Employee Guide: Health Reimbursement Arrangements (HRA)
  • IIAS Merchant List
    This is a list of merchants who implemented or intend to implement the SIGIS IIAS standard. The planned merchant implementation dates shown have been provided by the merchants and may be subject to change. When using your debit card at a merchant with IIAS, you will not be asked for additional substantiation as this is done at the point of service by the merchant. If you do not find your favorite merchant listed here, check with your merchant to see if they implemented a proprietary (non-SIGIS) IIAS or plan to implement IIAS in the future. This list does not include merchants adopting an IIAS solution other than the SIGIS Standard. SIGIS certification is not a requirement of the IRS and some merchants, such as Walgreens, have implemented their own proprietary IIAS. Walgreens' IIAS is fully compliant with the IRS requirements.
  • IRS Publication 502 - Medical Expenses
    IRS Publication that is a guide for eligible expenses for FSA, HRA, HSA.
  • IRS Publication 969 - Reimbursement Accounts (FSA, HSA, HRA)
    The IRS Publication that provides guidance on different types of reimbursement accounts that includes flexible spending accounts, health savings accounts and health reimbursement arrangements.
  • Medical Necessity Form
    Use this form to communicate to Discovery Benefits a medical necessity for a dual-purpose item. This form will be required to be completed periodically.
  • MSP Reporting Requirements for HRAs
    This outlines what Discovery Benefits is doing to comply and what it will ask its HRA clients to provide to meet the CMS requirements.
  • Over-the-Counter Changes in 2011
  • Reimbursement Request
    Use this form to request reimbursement for any out-of-pocket medical or dependent care expenses. If you need assistance with completing the form, give us a call at 866-451-3399 between 7:00 a.m. and 7:00 p.m. CST Monday through Friday.

COBRA

  • Authorized Representative (HIPAA) COBRA
    This form is to document the designation of one or more Authorized Representatives for a participant. This form authorizes the release of COBRA information to the named representative(s).
  • Benefits Termination Form - COBRA
    This form is to terminate one or more benefit(s) continued through COBRA. If participating in ACH, please note we need to receive notification at least 15 days prior to the 1st of the month of your requested termination. If this form is received after that timeframe, we cannot guarantee that the ACH payment for that month will be canceled. However, if a payment is withdrawn, you will be refunded via check.
  • CMS - Request for Review if Denied
  • COBRA - Addition of Dependent
    This is for adding any dependents to your coverage. If the additional dependent is due to a marriage, birth or adoption, notification of the additional dependent must be made within 30 days of the qualifying event, or the request may be denied by the insurance carrier.
  • Contact Information Change
    This form is to update contact information such as mailing address, telephone number, and email address.
  • Second Qualifying Event - COBRA
  • Social Security Disability Extension
    This form is to apply for or cancel a Social Security Disability Extension related to your COBRA coverage.

Transportation

General Forms

  • 90% Rule Merchant List
    This is a list of merchants that have registered with SIGIS as meeting the IRS 90% Rule which requires that at least 90% of gross sales are from prescriptions/Rx or qualified over-the-counter health care products. Meeting this rule means that the debit card may be used at this location. You will still be required to submit substantiation for purchases made at merchants meeting the 90% rule and who do not have IIAS.
  • Authorized Representative Request (HIPAA)
    Complete this form to communicate authorization to DBI to release information on your FSA, HSA, or HRA to another individual.
  • COBRA - Addition of Dependent
    This is for adding any dependents to your coverage. If the additional dependent is due to a marriage, birth or adoption, notification of the additional dependent must be made within 30 days of the qualifying event, or the request may be denied by the insurance carrier.
  • Consumer Portal Guide
  • Consumer Portal Guide – Single Page
  • Consumer Portal Guide for Direct Deposit
  • Consumer Portal Guide to Order Additional Debit Cards
  • Debit Cards Receipt and Substantiation Form
  • Direct Deposit Form
    Complete this form to provide Discovery Benefits with your bank account information for the direct deposit of reimbursement and distribution requests.
  • Discovery Benefits Privacy Notice
  • Discovery Benefits Terms of Service
  • Expense Eligibility List (Health FSA and HSA)
    This is a summary of common expenses claimed against Health FSAs and Health Savings Accounts (HSAs). Due to frequent updates to the regulations governing FSAs and HSAs, this list does not guarantee reimbursement but instead is to be utilized as a guide for the submission of claims.
  • Expense Eligibility List (Limited Medical Savings Account)
    The following is a summary of common expenses claimed against Limited Medical Savings Accounts. Due to frequent updates to the regulations governing LMSAs, this list does not guarantee reimbursement but instead is to be utilized as a guide for the submission of claims.
  • Health Care Reform - Participants
  • IIAS Merchant List
    This is a list of merchants who implemented or intend to implement the SIGIS IIAS standard. The planned merchant implementation dates shown have been provided by the merchants and may be subject to change. When using your debit card at a merchant with IIAS, you will not be asked for additional substantiation as this is done at the point of service by the merchant. If you do not find your favorite merchant listed here, check with your merchant to see if they implemented a proprietary (non-SIGIS) IIAS or plan to implement IIAS in the future. This list does not include merchants adopting an IIAS solution other than the SIGIS Standard. SIGIS certification is not a requirement of the IRS and some merchants, such as Walgreens, have implemented their own proprietary IIAS. Walgreens' IIAS is fully compliant with the IRS requirements.
  • IRS Publication 503 - Dependent Care
    IRS Publication that provides guidance on what is and is not an eligible dependent care expense.
  • Over-the-Counter Changes in 2011

FSA

HSA

HRA

COBRA

Transportation

General Forms

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