ET-4427
Form Active Employee / Retiree / Other Benefit Recipient

Statement of Incapacity for Finances and Property

Form for the member’s physician to complete if the member cannot manage property, finances or business affairs because of an impairment in the ability to receive and evaluate information or make or communicate decisions even with the use of technological assistance.

HSA Eligible Expenses

An eligible expense is a health care service, treatment, or item the IRS states can be paid for without taxes. Eligible expenses can be incurred by you, your spouse, or qualified dependents. The Health Savings Account (HSA) can only be used to pay for eligible medical expenses incurred after your HSA was established.

Program Option
  • State Employee and Retiree Health Plan & Supplemental Benefits
Plan Year
  • 2024