Request for Reimbursement from FSA or HRA EMPLOYEE INFORMATION Employer Employee Last Name Employee Mailing Address (Street) Home Phone Please check if address above is new First Name (Apt. #) Work.
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How to fill out the Manley Forms online
This guide provides a clear and supportive overview for users on completing the Manley Forms online. Whether you are new to filling out these forms or looking for specific assistance, this guide will walk you through each step in detail.
Follow the steps to complete the form accurately.
- Click the ‘Get Form’ button to obtain the Manley Form and open it in an online editor.
- Fill in the employee information section with the employer's 11-digit Manley ID number, your last name, first name, and middle initial. Ensure you provide your mailing address, including the street, apartment number if applicable, city, state, and ZIP code.
- Enter your home and work phone numbers. If the address provided is new, check the corresponding box.
- Choose how you would like your expenses processed if your plan allows for a grace period by marking the appropriate box. You can select either to process from the current plan year or the previous plan year.
- In the reimbursement request section, identify the type of expense for which you are requesting reimbursement by checking either ‘Unreimbursed Health-Related Expense (HRE)’ or ‘Other Health-Related Premium (OHP)’. Fill in the amount, service date, and a brief description for each expense listed.
- For dependent care expenses, enter the amount and the period of service, along with the signature of the provider if necessary.
- Calculate the total reimbursement requested and enter that amount at the bottom of the section.
- Sign and date the authorization section, confirming all statements are true and that you understand the information provided. Make sure your flexible spending account or health reimbursement arrangement can be reduced by the requested amount.
- Attach any necessary documentation as explained in the instruction sections related to unreimbursed health-related expenses, other health-related premium expenses, or dependent care expenses.
- Once the form is fully completed, save any changes made. You can then download, print, or share the completed form as needed.
Complete your Manley Forms online today for a smooth reimbursement process.
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