Get Health Savings Account Reimbursement Form - Bclpsbborgb

The Health Savings Account Reimbursement Form - Bclpsbborgb enables users to request reimbursement for qualified medical expenses. This guide provides clear, step-by-step instructions for completing the form online, ensuring a smooth submission process.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your personal information. Enter your HSA number or Social Security number, full name (first, last, and middle initial), address (street, city, state, and ZIP), phone number, and email address.
3. In the reimbursement information section, provide the provider's name, the date of the expense, the patient's name, and select the type of expense (medical, vision, dental, prescription). Enter the total reimbursement amount.
4. Choose your preferred reimbursement method. Indicate whether you would like to receive a check (note the $2 fee for paper checks) or request a transfer of funds directly to your bank account. If transferring funds, provide the account type, financial institution name, location, account number, and routing number.
5. Sign the reimbursement authorization. This includes printing your name, signing, and dating the authorization to confirm that the information provided is truthful and complete.
6. Once all fields are filled out, review the form for accuracy. Save your changes, and then you can choose to download, print, or share the completed form as necessary.

Complete your Health Savings Account Reimbursement Form online today for a seamless reimbursement experience.