Get Hra Activation Form - Ameriflex

The HRA Activation Form is an essential document for activating your Health Reimbursement Account once your medical deductible has been met. This guide will provide you with clear and supportive guidance to fill out the form accurately and effectively.

Follow the steps to complete the HRA Activation Form

1. Press the ‘Get Form’ button to obtain the HRA Activation Form and open it for editing.
2. Begin by entering the employer name in the designated field. Ensure this is the accurate name of your workplace.
3. Fill in your full name in the employee name field. This should match the name on your legal documents.
4. Provide your telephone number in the telephone field. Use a valid number where you can be reached.
5. Complete your address by filling out the employee address field, including your city, state, and ZIP code.
6. Enter your email address in the email field. Make sure it is an active account for future correspondence.
7. Provide your Social Security Number in the appropriate field while ensuring your personal data is protected.
8. Input the start and end date for the plan year in their respective fields. Check your plan documents for these dates.
9. Indicate whether you are currently enrolled in Medicare or have ever been enrolled by selecting 'Yes' or 'No'. If you select 'Yes', you will need to provide your Medicare Claim Number.
10. In the AmeriFlex Convenience Card® Activation section, express your request to activate your HRA Account on the card.
11. Document the amount to be applied towards your deductible next to the relevant field.
12. Sign and date the form at the end to authenticate your submission.
13. Submit the completed form to AmeriFlex via mail, fax, or email as listed in the instructions. Ensure that you include a copy of your Explanation of Benefits.

Complete the HRA Activation Form online to activate your benefits today.