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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
    • Claims Submission
    • No Surprises Act
  • Employers
    • Machine Readable File Links
    • Providers
      • No Surprises Act
  • Providers
    • No Surprises Act
  • Brokers
  • Member Portal Login
  • Home
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  • Forms

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.

 

  • Additional Debit Card Form
  • Affidavit of Domestic Partnership Status
  • Authorization to Release Information
  • Collecting Surprise Billing Info_ Open Negotiation Notice
  • Confidential Communication Request
  • Dental Claim Form
  • Dependent Care Only FSA Form
  • Direct Deposit Form
  • Disabled Dependent
  • Disclosure Accounting Request
  • FSA Fax Form
  • Health Only FSA Form
  • Healthcare & Dependent Care FSA Form
  • HRA Claim Form
  • Limited Purpose FSA Form
  • Medical Claim Form
  • Medical Travel Expense Reimbursement Claim Form
  • Parking & Transit Claim Form
  • PHI Access Request
  • PHI Amendment Request
  • 1 (current)
  • 2

© 2025 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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