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Use/Survivor SSN* (last 4 digits) (if applicable) Email Address (complete only if new) CERTIFICATION AND AUTHORIZATION Signature of Account Holder X Date I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible expenses incurred by myself or an eligible dependent while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have already received these products and services and I have.

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Your ID code is a 4-digit combination of your day of birth and the last 2 digits of your SSN. For example, if you were born on the 8th day of the month and the last 2 digits of your SSN are 12, your ID Code would be 0812.

If you are a new Medicare Part B enrollee in 2023, you will be reimbursed the standard monthly premium of $164.90 and will only need to provide a copy of your Medicare card.

General Purpose Medical Reimbursement Account (MRA) The Medical Reimbursement Account allows you to set aside pre-tax money to reimburse yourself for out-of-pocket medical related expenses incurred by you or your dependents that are not paid by your insurance or reimbursed by any other benefit plan.

You must send an itemized bill with a completed Medicare Form 1490S for reimbursement. You're responsible for any excess charges, deductible and coinsurance. Medicare may pay the provider or pay you directly. Once the claim is processed, you may be due a refund or owe a balance to your provider.

Your MRA funds are used first to pay for eligible medical and prescription drug out-of-pocket expenses. Once there is no money left in your MRA, your HCSA funds can be used to pay for eligible out-of- pocket medical and prescription drug expenses.

Medicare Reimbursement Account (MRA) Basic Option members who pay Medicare Part B premiums can be reimbursed up to $800 each year! You must submit proof of Medicare Part B premium payments through the online portal, EZ Receipts app or by fax or mail.

Log in to your account at https://participant.wageworks.com/sfmra to file your claim electronically and upload your documentation. Claim processing time: Claims will be processed within 2 business days after receipt of the form.

Can I simply cash out my MRA? No. MRA funds can only be withdrawn by submitting claims for qualified medical expenses.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232