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Deductible Verification Form

Deductible Verification Form - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, Health Savings Account, Resources

Deductible Verification Form
If enrolled in a Combination FSA or HRA, a completed Deductible Verification Form must be on file in order for a participant to
be reimbursed for general-purpose medical expenses. Until a completed form is submi�ed, only expenses for dental, vision and
preventative care are eligible for reimbursement.
What is a combination FSA or HRA? A Limited Medical FSA or Limited HRA (vision, dental and preventative expenses only) that is
converted to a general-purpose FSA or HRA once a participant has met the statutory deductible.
*Required Fields
Updates or changes to your profile can be made by logging into your account at www.discoverybenefits.com.
Step 1: Participant Information
Step 2: Plan Information
Step 3: Participant Authorization
866-451-3399 · 866-451-3245
PO Box 2926 · Fargo, ND 58108-2926

*Participant Name (First, MI, Last)
To the best of my knowledge, all of the information provided on this form is accurate. I have satisfied the statutory deductible and
would now like to receive reimbursement from my account for general-purpose medical expenses.
Please note that in order for general-purpose medical expenses to be eligible for reimbursement, the dates of service must be on or
a�er the date the statutory deductible was met. Deductible amounts used to meet the statutory deductible are not reimbursable.
Manual reimbursement is required for all general-purpose medical expenses and will not be reimbursed from your debit card (if
*Date Deductible Was Met (mm/dd/yyyy) Individual Deductible
Include dollar amount:
2015: $1,300 | 2016: $1,300
Family Deductible
Include dollar amount:
2015: $2,600 | 2016: $2,600
*Employer Name (Do not abbreviate)
*Plan Year Start Date (mm/dd/yyyy)
*Social Security Number
Employee ID
*Signature *Date
*Plan Year End Date (mm/dd/yyyy)
*Select One: $ $
Revised 9/16/15