Participant Resources for all Benefits
This page provides you with all forms and instructional guides for your EMPOWER Plan.
This page shows resources for all benefits. If you wish to view only the resources for your Plan, click the appropriate button below.
Table of Contents
Forms
EMPOWER encourages you to use the Online Portal to ensure the fastest service (see the Instructional Guides and Tutorials section below for more information). However, forms are provided below for you to fill out and return to EMPOWER as an alternate way to use your benefits.
HSA Contribution Form
Use this form to make an HSA contribution outside of your Employer’s payroll.
HSA Custodial Agreement
All HSA participants must either accept the HSA terms on the Consumer portal or sign this form and return the last page to EMPOWER.
HSA Transfer Form
Form to transfer the balance from another account to your current EMPOWER HSA account.
SpHRA Claim Form
This form allows participants to seek reimbursement from the Spousal Incentive HRA.
Additional Resources
ICHRA Notice
the ICHRA Notice contains information for your specific plan. contact your Employer if you have not been provided with this Notice.
QSEHRA PTC Worksheet
Use this form to determine the impact of your QSEHRA on your Premium Tax Credit.
QSEHRA Notice
the QSEHRA Notice contains information for your specific plan. contact your Employer if you have not been provided with this Notice.
Instructional Guides and Tutorials
HRA Plan Fact Sheet (PDF)
Details the plan-specific details of your HRA.
- Log into the EMPOWER Online Portal.
- Click on Tools & Support.
- On the Tools & Support Page, click on the HRA Plan Fact Sheet link to download.
Online Portal Quick Start Guide for FSA and HRA
Learn how to use the Online Portal (FSA and HRA).
