Debit Card Enrollment

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!

By clicking this box, I hereby certify that I am the person whose name appears above, and that my name, as it appears above, is intended for purposes of this to be my genuine signature and acknowledgement of this document.