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DEBIT 11/17 P.O. BOX 4346 • MISSOULA MT 59806 [PHONE REDACTED] • [PHONE REDACTED] www.askallegiance.com DEBIT CARD ENROLLMENT FORM Personal Information Employer Name SSN Address City Zip Birth Date Male Female Married Single Email Address► Cardholder Use Acknowledgement 1. I may only use the card to pay for eligible medical expenses. 2. I may not use the card for expenses already reimbursed. 3. I may not seek reimbursement under any other health plan for expenses paid with the card. 4. I will acquire and provide documentation for expenses paid with the card. 5. I have been provided an explanation of the fees associated with the debit card. Employee Signature: Date: As a security measure your card will be mailed in a plain white envelope. Please be careful not to throw it away with the junk mail! SIGN