Get American Health Resources

HSA Claim Form Please Print Mail or fax to American Health Resources 11 North 2nd Avenue St. Charles IL 60174 Phone Fax 800-570-3757 888-815-3921 Insured Name Address City State Please submit the following Provide bill or Explanation of Benefits EOB Zip Last 4 digits of SS Employers Name Requested amount Reimburse me Pay provider Do not negotiate a better price for me Provider Name Patient Name Employee Signature Provider Phone Number Provider Acct Number 1 The reimbursement request is for an eligible expense 3 Please attach a copy of the insurance explanation of benefits EOB or bills to document each reimbursement request. 4 Please do not submit originals of bills or insurance statements. Keep originals for your records. PLEASE NOTE If you incur a large claim 250 or more and you do not have enough in your account to cover it we can set up a payment plan to pay your doctor or hospital out of your account for you. Please call us at 800-570-3757 if you want us to make these arrangements for you. I hereby authorize AHR its representatives and agents to utilize and release personal health care information including this authorization as I have provided to them for the purpose of paying medical claims and/or obtaining a reduction in medical claim liability on behalf of me or one of my family members. I also authorize them to act as my/the patient s authorized representative for those purposes and authorize my health care provider to disclose or utilize such information in discussions with them for such purpose. I authorize the transmission of this information via email or facsimile and hold AHR its representatives and agents and my health care providers harmless from any and all claims that might arise from the risks associated with accidental disclosure of medical information which is inherent in an email or facsimile transmission* This authorization in its entirety may be revoked in writing at any time by me except to the extent that any actions have been taken in reliance thereon* This authorization is valid for the period of time necessary to pay the claims contained herein and shall expire when these financial transactions have been concluded*. 4 Please do not submit originals of bills or insurance statements. Keep originals for your records. PLEASE NOTE If you incur a large claim 250 or more and you do not have enough in your account to cover it we can set up a payment plan to pay your doctor or hospital out of your account for you. PLEASE NOTE If you incur a large claim 250 or more and you do not have enough in your account to cover it we can set up a payment plan to pay your doctor or hospital out of your account for you. Please call us at 800-570-3757 if you want us to make these arrangements for you. I hereby authorize AHR its representatives and agents to utilize and release personal health care information including this authorization as I have provided to them for the purpose of paying medical claims and/or obtaining a reduction in medical claim liability on behalf of me or one of my family members.