Information

Please complete all required fields below to ensure your form is processed promptly. Fields marked with * are required.

First name*: Please provide valid First name.

Last name*: Please provide valid Last name.

Middle initial: Please provide valid Middle initial.

*Date of birth: Please provide your date of birth.

Address*: Please provide valid Address.

*City: Please provide valid City. *State: Select AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NB NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Please select a valid State.

ZIP code*: Please provide valid ZIP Code.

Email*: Please provide valid Email address.

Phone number*: Phone format: xxx-xxx-xxxx Please provide valid Phone number.

Direct deposit verification

You are electing to have your reimbursement made by direct deposit to a designated bank account. Fields marked with * are required.

Please note that Direct Deposit requests must be verified through a micro-deposit authentication process handled by UPMC Benefit Management Services. Since this process generally takes 2-3 business days, the member's reimbursement will be sent by check.

Account Information

Account type*:

Signature/Authorization

Please acknowledge the following information before signing. *These fields are required.

Full name/Signature*: Please provide valid Full name/Signature

Phone number*: Phone format: xxx-xxx-xxxx Please provide valid Phone number

Date:

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