Get Health Reimbursement Arrangement (hra) Request For Reimbursement Form Please Mail Completed Form

Filing a Health Reimbursement Arrangement (HRA) Request for Reimbursement Form can seem daunting, but this guide aims to simplify the process for you. Follow these straightforward steps to ensure that your reimbursement request is completed accurately and efficiently.

Follow the steps to complete your HRA reimbursement request.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling out the employee's information section. Include your company name, group number, employee ID number, and full name (first, initial, last). Confirm if there is an address change by selecting 'Yes' or 'No', then provide your current address, city, state, and ZIP code.
3. In the Health Reimbursement Arrangement section, list each expense incurred. For each entry, enter the date the expense was incurred, the name of the patient, the service provider's name, a brief description of the expense, and the amount. Make sure to fill in all fields completely.
4. After listing all relevant expenses, calculate the total reimbursable expenses and enter this amount in the designated field.
5. Sign the form as the employee and date it. By signing, you certify that the expenses listed were incurred by you or your dependents and qualify for reimbursement under the plan.
6. Attach the required documentation, such as proof of expenses or a medical insurance Explanation of Benefits, if applicable. Ensure that all supporting documents are included.
7. Once you have completed all fields and attached the necessary documentation, save the changes to your form. You may then download, print, or share the form via the available options.

Complete your HRA reimbursement request form online today to streamline your reimbursement process.