Participant Resources for QSEHRA
Participant Resources for QSEHRA
This page provides you with all forms and instructional guides for your EMPOWER QSEHRA Plan.
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.
Direct Deposit Authorization Form
Add or change an existing bank account to receive reimbursements right to your bank account
Additional Resources
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.
