Documents & Claim Forms
BAC’s claim forms and documents can be filled out either digitally on your computer/tablet or physically on a printed copy and returned either by mail, facsimile or email. If you are emailing BAC a form that contains HIPAA information we recommend you send it using our secure email messaging center.
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OPTUM Bank HSA Account Creation Form
Interactive Adobe Acrobat PDF -
Glossary of Health Coverage & Medical Terms
Adobe Acrobat PDF -
Adult Dependent Child Questionnaire
Interactive Adobe Acrobat PDF -
FSA Flexible Spending Account Claim Form
Interactive Adobe Acrobat PDF -
DCAP Dependent Care Claim Form
Interactive Adobe Acrobat PDF -
Direct Deposit Authorization Form
Interactive Adobe Acrobat PDF -
Provider Claim Status Request Form
Interactive Adobe Acrobat PDF -
COBRA - Notice of Qualifying Event
Interactive Adobe Acrobat PDF -
Certification of Student Enrollment
Interactive Adobe Acrobat PDF -
Dental Claim Form
Adobe Acrobat PDF -
Medical Claim Form
Interactive Adobe Acrobat PDF -
STD Short Term Disability Claim Form
Adobe Acrobat PDF -
Vision Claim Form
Adobe Acrobat PDF -
Attending Physician’s Statement of Disability
Adobe Acrobat PDF -
Dependency Questionnaire
Interactive Adobe Acrobat PDF -
Your Rights & Protections Against Surprise Medical Bills
Adobe Acrobat PDF