Get Hsa Reimbursement Form - Healthequity

This guide provides clear and detailed instructions on how to fill out the HSA Reimbursement Form from HealthEquity online. By following these steps, users can ensure their reimbursement requests are submitted accurately and efficiently.

Follow the steps to complete the HSA Reimbursement Form online.

1. Press the ‘Get Form’ button to retrieve the HSA Reimbursement Form in your document editor.
2. Input the primary account holder information including last name, first name, street address, city, state, ZIP code, email address (which is mandatory), daytime phone number, and the last four digits of either your Social Security Number or HealthEquity ID number.
3. In the reimbursement information section, fill in the provider name, date of expense, patient name, and total reimbursement amount. In the type of expense section, indicate the applicable categories by checking the appropriate boxes, whether medical, prescription, dental, or vision.
4. Select your preferred reimbursement method. You can choose from the following options: Option 1 for check (note that this method is slower and incurs a fee), Option 2 for verified electronic funds transfer (EFT), or Option 3 to transfer to a specified account (requiring additional account details). If choosing Option 3, ensure to provide the financial institution, the city/state, routing number, and account number.
5. For Option 3, remember to include a copy of a voided or actual check with your filled form.
6. Complete the reimbursement authorization by printing your name, signing the form, and dating it to confirm that the information provided is complete and true.
7. Once all fields are completed, review the form for accuracy. Finally, save your changes and download, print, or share the completed document as needed.

Start filling out your HSA Reimbursement Form online today to ensure a smooth reimbursement process.