Get Hra Request For Reimbursement Of Non-recurring - Bac Local 1 - Bac1mn-nd

Filling out the HRA Request For Reimbursement Of Non-Recurring - BAC Local 1 - Bac1mn-nd form online can be straightforward with the right guidance. This comprehensive guide will walk you through each section of the form, ensuring that you complete it accurately and efficiently.

Follow the steps to complete your reimbursement request successfully.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Begin by filling out the participant information section. Ensure you provide the plan name, your full name, social security number, gender, marital status, and date of birth.
3. Next, enter your address along with your home and work phone numbers. Indicate whether your address has changed.
4. In the claim information section, specify for whom the claim is being made, selecting from options like self, spouse, dependent child, or other dependent.
5. Proceed to the coverage information section. Confirm whether you were enrolled in employer-sponsored group health plan coverage during the expense period. If yes, include your signature to attest to this.
6. After completing the coverage section, summarize your healthcare expenses. For each expense, provide the incurred date, the provider’s name, a brief description of the claim, and the amount you wish to be reimbursed.
7. Certify that all expenses for reimbursement were incurred by you or your eligible dependents, that they are not reimbursable under any other health plans, and that you are solely responsible for the accuracy of the information.
8. Complete the member’s signature and date the form to finalize your submission.
9. Once you have filled out all sections, make sure to save the document. You can download, print, or share the form as needed to send it to the specified address.

Complete your HRA Request For Reimbursement online today for a smooth and efficient process.