Debit Card Enrollment
(Please note: When your email address is included above your debit card receipt notifications will be e-mailed to this address.)
Complete Spouse Information ONLY if your employer allows spouse cards.
If you are unable to complete this information at this time please print the
Debit Card Enrollment Form
, complete and submit to Allegiance later.
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!
Click for Additional Debit Card Information
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 debit card election to be my genuine signature and acknowledgement of this document.
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