How To Get Forms

This article applies to you if you have a Via Benefits reimbursement account (sometimes known as a Health Reimbursement Arrangement)*. 

Paper forms are available to set up direct deposit or submit reimbursement requests. However, using a paper form isn't the preferred method because it lengthens the processing time of your requests. 

Reimbursement Request Form

You may submit a reimbursement request by returning a completed Reimbursement Request Form. The form is available by calling us at 1-866-322-2824 and using our automated voice system or by speaking with a Via Benefits representative.

Using a paper form is less secure and may take up to 10 days longer than submitting your request on the website or on the mobile app. Reimbursement requests submitted on the mobile app or website take up to five business days to process. Read Submitting a Reimbursement Request to learn more. 

Direct Deposit Authorization Form

You may set up direct deposit or update your banking information by returning a completed Direct Deposit Authorization Form. The form is available by calling us at 1-866-322-2824 and using our automated voice system or by speaking with a Via Benefits representative.

It may take up to 10 business days to receive and validate your Direct Deposit Authorization Form. Forms received between January 1 and March 31 can take longer to be processed and validated. Direct deposit banking information validates in three to five business days if submitted on the mobile app or website. A voided check is also required if you use a paper form. This isn't needed for mobile app or website authorization. Read Direct Deposit to learn more.

Special Payment Benefit Form 

The Special Payment Benefit Form is only available by calling us and speaking with a Via Benefits representative.

*Via Benefits reimbursement accounts are administered by Extend Health, LLC.