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Contact Us Careers Blog
EBPA LLC Logo
  • Why EBPA
    • About Us
    • About Self-Funding
    • Our Offerings
      • Medical & Dental
      • FSA Health & Dependent Care
      • Parking & Transit
      • COBRA
      • Direct Billing Services
      • Custom Solutions
    • Compliance, Security & HIPAA
  • Our Services
    • Claims & Benefit Administration
    • Cost Management
    • Consumer Engagement & Care Navigation
    • Next Generation Analytics
  • Members
    • Forms
    • FAQs & How To's
  • Employers
  • Providers
  • Brokers
  • Member Access
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Forms

Need a form? Use the below forms and upload them on our secure portal.

Can't find what you are looking for? Contact us and speak with one of our members service representatives.

 

  • Authorization to Release Information
  • Confidential Communication Request
  • PHI Amendment Request
  • Disclosure Accounting Request
  • PHI Access Request
  • Cobra FAQ
  • Direct Deposit Form
  • Dental Claim Form
  • Healthcare & Dependentcare FSA Form
  • Wellness Form
  • FSA Fax Form
  • Limited Purpose FSA Form
  • Retiree HRA Form
  • Parking Transit Claim Form
  • Dependentcare Only FSA Form
  • Healthcare Only FSA Form
  • Medical Claim Form
  • HRA Claim Form
  • Additional Debit Card Form

© 2021 EBPA LLC

37 Industrial Drive, Exeter, NH 03833 | 800-258-7298 | TTY Number Dial 711

46 Bowdoin Street, South Burlington, VT 05407-2365 | 800-525-8788 | TTY Number Dial 711

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