[San Francisco City Option] MRA Enrollment Form

SF MRA Enrollment Form

Complete this form to determine if you qualify for a Medical Reimbursement Account (SF MRA). After you submit this form, SF City Option (SFCO) will let you know if you are eligible for SF MRA within 1-3 weeks.

If you have any questions, please email info@sfcityoption.org.

* Required Fields

First Name

Last Name

Date of Birth

Month

Day

Year

Social Security Number *

SF City Option will not share your personal information with immigration or law enforcement. Your immigration status will not affect your eligibility for the SF City Option program.

We will disclose your personally identifiable information, including your SSN, date of birth, and name, to Covered California to determine whether you are eligible to apply your SF City Option funds to the payment of premiums for an insurance plan purchased through Covered California and, if you are eligible, to assist you with applying your SF City Option funds in this manner. If you do not authorize SF City Option to disclose your personally identifiable information to Covered California, please check the box below.

Do not disclose my personally identifiable information to Covered California.

Mailing Address

Apartment / Unit / Building / Floor

City

State

Zip Code

Primary Phone Method

Primary Phone Number

Email Address

By providing your phone number and/or email address you agree to receive emails, calls, or texts from the SFCO program. If you want to stop receiving SFCO emails, calls and/or texts, please email info@sfcityoption.org.

Preferred Method of Contact

Mail

Phone

Text

Employer Name(s)

What is your preferred spoken language?

If you answered "Not Listed", please specify.

What is your race?

American Indian or Alaskan Native

Asian

Black or African-American

Native Hawaiian or Pacific Islander

White/Caucasian

Two or more races

Prefer not to say

Prefer to self-describe

If you answered "Prefer to self-describe", please specify.

Are you of Latino/a/x, or of Spanish origin?

Yes

Prefer not to say

Certification *

I certify that the information provided on this form is true and accurate to the best of my knowledge. I understand if my application is approved for an SF MRA, only eligible payments made by my employer(s) will be transferred to an SF MRA. If approved for SF MRA, I agree to have any future payments from my employer(s) deposited into an SF MRA.

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