Forms Library
For faster reimbursement, download Igoe Mobile on the Apple App Store or Google Play Market.
Submitting Claims
The best and most secure way to transmit requests is by submitting claims online through your Igoe Participant Portal account or by using Igoe Mobile available on the App Store or Google Play Market. If you are unable to use these tools, manual forms are available at the bottom of this page and contain submission instructions. Our Forms Library also includes several helpful templates to make getting reimbursed easier for more challenging expenses like independent day care providers, orthodontia and dual-purpose expenses that may require a prescription.
Our forms are listed in alphabetical order with the exception of COBRA documents which are grouped together at the end of the form library. If you want to pull money from your spending account, we recommend using Igoe Mobile or the Igoe Participant Portal.
Additional Cardholder Request Form
Additional Cardholder Request Form
Use this form to request an additional Benefits Card for a tax dependent that is 18 years of age or older.
Claim Appeal Form
Claim Appeal Form
Use this form if you experienced a claim denial that you believe is incorrect. In most cases, appeals will need to be reviewed by a special appeals committee run by the employer Plan Sponsor. Please allow 7-10 business days for initial review results.
Commuter Cashback Form
Commuter Cashback Form
While the IRS requires that the Benefits Card or similar fare media be used to access transit funds (parking funds are excluded from this requirement), there are situations where a Benefits Card may malfunction, may not be accepted, or you may not have your Benefits Card available. In these situations, you may use this form to seek reimbursement from your commuter account.
Dependent Care Reimbursement Request and Provider Receipt
Dependent Care Reimbursement Request and Provider Receipt
Complete this form to meet the requirements for requesting reimbursement from your dependent day care account. This form also includes an optional provider acknowledgement section that may act as your receipt for expenses incurred should you not have access to sufficient receipt documentation directly from your day care service provider.
FSA Reimbursement Request Form
FSA Reimbursement Request Form
For faster reimbursement, login to your Igoe Mobile or Participant Portal Account. If you are unable to access these tools, you can also use this form to seek reimbursement from your FSA.
Flexible Benefits Card Substantiation Coversheet
Flexible Benefits Card Substantiation Coversheet To verify a Benefits Card substantiation when requested, login to your Igoe Mobile or Participant Portal account. If you are unable to access these tools, you may use this coversheet to send in the requested supporting documentation. Credit card receipts are not valid forms of documentation. Please include a document that shows the following:
- Date of the service or procedure
- Name of the service provider/retailer
- Description of the service provided or product purchased
- Name of the person for whom the service or product was purchased
- Cost of the service or product that was purchased
All 5 points of verification are required by the IRS to authenticate certain Benefits Card transactions.
HRA Reimbursement Request Form
HRA Reimbursement Request Form
For faster reimbursement, login to your Igoe Mobile or Participant Portal Account. If you are unable to access these tools, you can also use this form to seek reimbursement from your HRA.
HSA Account Closure Form
HSA Account Closure Form
Use this form to close your HSA.
HSA Contribution Correction Form
HSA Contribution Correction Form
Use this form to correct a contribution you made to your HSA that was applied to an incorrect tax year.
HSA ACH Dispute Form
HSA ACH Dispute Form
Use this form if you see an electronic fund transfer that you believe to be in error or otherwise unauthorized in your HSA.
HSA Authorized User Form
HSA Authorized User Form
Use this form to request changes to authorized users on your HSA.
HSA Beneficiary Form
HSA Beneficiary Form
Use this form to designate a beneficiary for your HSA.
HSA Change of Power of Attorney
HSA Change of Power of Attorney
Use this form and send it along with a copy of your DURABLE Power of Attorney documentation to request a Power of Attorney be added to your HSA.
HSA Consent to Electronic Communications
HSA Consent to Electronic Communications
Use this form to consent to receiving electronic communications for your HSA. Go green!
HSA Contribution Form
HSA Contribution Form
Use this form to add a contribution to your HSA. You can also do this via Igoe Mobile or the Igoe Participant Portal.
HSA Death Distribution Form
HSA Death Distribution Form
Use this form to authorize a distribution of assets from a decedent’s HSA, directly to you as the beneficiary or to the estate of the deceased. For distribution amounts less than $2,500, you must provide a copy of the death certificate. For distribution amounts greater than $2,500, you must provide a certified copy of the death certificate. Guardianship paperwork must be submitted if beneficiary is a minor.
HSA Distribution of Excess or Mistaken Contributions Form
HSA Distribution of Excess or Mistaken Contributions Form
Use this form to reverse excess contributions made to your HSA. The IRS specifies the total annual contribution limits which can be made each year. You can find those limits online at www.IRS.gov. Funds can be returned to you via ACH transfer or check. You may wish to review IRS Publication 969 found at
www.irs.gov/pub/irs-pdf/p969.pdf.
HSA Account Holder Name Change Form
HSA Account Holder Name Change Form
Use this form to change the legal name listed in your HSA.
HSA Rollover Distribution Form
HSA Rollover Distribution Form
Use this form to withdraw all funds and close your existing HSA so that you
can deposit those funds into your new HSA (i.e., rollover contribution).
HSA Transfer Due to Divorce Form
HSA Transfer Due to Divorce Form
Use this form to authorize a transfer of assets from your existing HSA to your ex-spouse’s HSA as a result of a divorce decree or legal separation.
HSA Transfer of Assets
HSA Transfer of Assets
Use this form to transfer assets from another HSA into an active WealthCare Saver* HSA account number (starting with 601).
HSA Withdrawal Form
HSA Withdrawal Form
Use this form to withdraw funds from your HSA.
Letter of Medical Necessity Template
Letter of Medical Necessity Template
This form was designed to provide a template for your physician to authenticate the eligibility of your expense. Please note that for expenses to be eligible under the medical FSA, they must be deemed medically necessary. The IRS requires a prescription that meets state requirements if your physician has recommended an over-the-counter (OTC) medicine or drug if you wish to seek reimbursement from an FSA or applicable HRA. Use of this form does not satisfy state prescription requirements. If you are in doubt about the eligibility of your expense, ask your provider to complete this form as a precaution.
Limited Purpose FSA Conversion Form
Limited Purpose FSA Conversion Form
Use this form to submit an Explanation of Benefits (EOB) showing that the deductible for your HDHP has been met. This is not a reimbursement request form and will not result in claim remittance.
LSA Reimbursement Request Form
LSA Reimbursement Request Form
This form can be used when seeking a post-tax reimbursement for qualified lifestyle expenses. To determine expense eligibility, please review your employer’s Lifestyle Benefits documentation.
Orthodontia Treatment Statement Template
Orthodontia Treatment Statement Template
This form may be completed by your provider to act as notification of the orthodontic treatment duration and cost. All items requested on this form are required for reimbursement. Either a copy of this completed form or a copy of your orthodontia contract indicating all items requested on this form must be submitted with your request for reimbursement to determine eligibility and payment.
Protected Health Information (PHI) Release Form
Protected Health Information (PHI) Release Form
Due to HIPAA requirements, this form is required each time you would like to have another individual or organization access Protected Health Information (PHI) related to any account that is maintained by Igoe.
COBRA Continuation Change Form
COBRA Continuation Change Form
Use this form if you are a COBRA member and wish to drop or terminate coverage for yourself or a dependent.
COBRA Open Enrollment Form
COBRA Open Enrollment Form
Use this form if you are a COBRA member and are eligible to make election changes during open enrollment.
COBRA Unallocated Premium Refund Request Form
COBRA Unallocated Premium Refund Request Form
Use this form to request a refund of premium payments that were not applied to your COBRA or employer-sponsored coverage.