Welcome New Members

Downloadable Forms

Member Reimbursement Form – Request reimbursement from your custodial account for qualified out-of-pocket medical expenses you have personally incurred related to your injury.

Attendant Care Reimbursement Form – Request reimbursement for expenses you incur from paying your attendant care providers.

Beneficiary Designation Form – Designate or change the beneficiary of your custodial account.  The individual(s) or estate you designate will receive the balance of your custodial account once it closes after your death. You may designate a beneficiary if you have a reversionary interest in your custodial account as specified in your settlement.

Authorization to Release Medical Information Form  – Grant access to designated individuals regarding your care, payment for your care, and administration of your Medivest account.