Get Wellmark Bcbs H-8772 2010-2025

Navigating the Wellmark BCBS H-8772 form can be straightforward with the right guidance. This guide will provide you with clear, step-by-step instructions to successfully complete the form online, ensuring that all necessary information is accurately captured.

Follow the steps to complete the Wellmark BCBS H-8772 form online.

1. Click 'Get Form' button to access the Wellmark BCBS H-8772 form and open it for editing.
2. Fill out the employee information section, including your name, Social Security number, home address, city, state, zip code, employer name, effective date, location or class, and date of birth.
3. Indicate your agreement to redirect your salary for the Employee Reimbursement Account by checking the appropriate box and providing the contribution amounts for the Medical Reimbursement Account based on your selections.
4. Select either 'General Purpose' or 'Limited Purpose' for the Medical Reimbursement Account. Remember, if contributions to a Health Savings Account (HSA) are made, the 'Limited Purpose' option is necessary.
5. Complete the section for the Dependent Care Reimbursement Account, ensuring you specify the amounts and confirm your income tax filing status if required.
6. If applicable, check the box to order a Blue Priority Flex Debit Card for your Medical Reimbursement Account and provide the name for any additional card for a spouse or dependent if needed.
7. Review the Automatic Reimbursement Authorization section. If you choose to authorize this feature, ensure you check the appropriate box and understand the conditions outlined.
8. Complete the Direct Deposit Authorization section, including the account type and banking information. Attach a voided check if you are electing direct deposit.
9. Finally, sign and date the Employee Authorization section to affirm your understanding and consent to the agreements outlined in the form.
10. Once you have filled out all sections of the form, make sure to save your changes. You can then download, print, or share the completed form as needed.

Now that you have your guide, start completing your Wellmark BCBS H-8772 form online to efficiently manage your employee benefits.