Get - Hra Claim Form 1112 (retain To Make Fillable).doc - Uwuabenefits

Filling out the HRA Claim Form 1112 is a straightforward process designed to ensure you can efficiently submit your claims for reimbursement. This guide provides step-by-step instructions to help you navigate each section of the form with ease.

Follow the steps to complete and submit your HRA claim form online.

1. To begin, locate and click the ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Provide your name, Member ID or Social Security number, and address in the designated fields. Ensure that all information is printed clearly and accurately.
3. Input your telephone number, including the area code. This information is essential for any follow-up regarding your claim.
4. If you have changed your address recently, check the box indicated to notify the plan administrator of your new address.
5. Proceed to itemize your medical expenses. For each claim, you will need to include the service date, description of the charges, provider name, and the amount requested for reimbursement.
6. List the name of the patient and their relationship to you for each service itemized. This helps confirm eligibility for reimbursement.
7. Add the total expenses at the bottom of the claim form. Ensure that the total exceeds $50.00, as this is the minimum requirement for reimbursement requests.
8. Certify your claims by signing the form and including the date of submission. This declaration confirms that you have not received reimbursement elsewhere and that the claims are for allowable expenses.
9. After completing the form, save your changes. Then, you have the option to download, print, or share the form as needed.

Complete your HRA claim form easily by following these steps online.