Debit Card Enrollment

Contact Info
( ) - x
Cardholder Use Acknowledgement
  • I may only use the card to pay for eligible medical expenses.
  • I may not use the card for expenses already reimbursed.
  • I may not seek reimbursement under any other health plan for expenses paid with the card.
  • I will acquire and provide documentation for expenses paid with the card.
  • I have been provided an explanation of the fees associated with the debit card.
As a security measure, your card will be mailed in a plain white envelope. Please be careful not to throw it away with the junk mail!