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Claims and Administration Forms

American Benefit Services is pleased to provide you with these forms to help you with your accounts with us. Please let us know if there are any other forms you might need.

All forms are in PDF (portable document format). To view a PDF file you must have the Adobe Reader. If you do not have the Adobe Reader installed on you computer, please download it from the Adobe Reader web site.


General Forms

 Medical Claim 

PDF Format

 Dependent Claim 

PDF Format

 Automated Clearing House (ACH) 
(Employer)

PDF Format

 Automated Clearing House (ACH) 
Individual

PDF Format

 Group Application 

PDF Format

 Payroll Deduction Autorization 

PDF Format

 Section 213 Expenses 

PDF Format


Health Savings Account (HSA) Forms

 HSA Enrollment 

PDF Format

 HSA Employer Information Sheet 

PDF Format

 HSA Enrollment Form Instructions 

PDF Format

 NBSC-ABS Authorization 

PDF Format


COBRA Forms

 Information Request 

PDF Format

 COBRA Admin Questionnaire 

PDF Format


Health Reimbursement Arrangement (HRA) Forms

 Election 

PDF Format


Flexible Spending Account (FSA) Forms

 Election 

PDF Format

 Worksheet 

PDF Format

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