DependentCardOrderForm
Dependent Card Order Form
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Indicates Required Fields
Employer Name:
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Employee First Name:
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Employee Last Name:
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SSN / ID Number:
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(No Dashes)
Phone :
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Email :
Dependent First Name:
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Dependent Last Name:
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Dependent Date Of Birth:
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(DD/MM/YYYY)
Dependent Identification:
--Select--
Spouse
Child
Other
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Shipping First Name:
Shipping Last Name:
Address:
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City:
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State:
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Zip:
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Terms & Conditions
I, the above referenced GetMOR Participant, wish to order a GetMOR Card for my eligible dependent(s) listed below. I have informed them they may only use the card to purchase eligible medical and/or health care related expenses that they incur. I have informed them they must keep all itemized receipts from any such expenditures and I will keep them with all other family medical care expenses and verify/report them as described in the Summary Plan Description.
Eligible dependents include your spouse, child(ren) under the age of 27, or individuals that could be listed on your tax return. Every dependent is not required to have a card, however, only those listed on the account will have access to account information.
There is no fee when ordering a GetMOR card for any dependent (limit 10).
Signature(Initials):
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