Debit Card Enrollment

Company:
Employee Name:
Participant Id: ?
Email:
Phone:xxx-xxx-xxxx


(Please note: When your email address is included above your debit card receipt notifications will be e-mailed to this address.) 

Gender:

Marital Staus:

Birth Date:


Please Read: 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.

Spouse Name:
SSN:
Birth Date:

Dependent Name:
SSN:
Birth Date:


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




 

Comments/Address Change: