Get Fsa Hra Mileage Claim Form - Heginc.com

Filling out the FSA HRA Mileage Claim Form is essential for users seeking reimbursement for medical travel expenses. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete your mileage claim form online

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Complete Part I, which includes entering your employee information. Fill in your Plan selection, employer name, your name, last 4 digits of your Social Security number, address, daytime phone, and evening phone. Indicate if you have a new address.
3. Move to Part II for Medical Mileage Expenses. Document your travel details by providing the date, provider name and address, type of service (medical, dental, vision, or prescription), number of miles traveled, mileage rate, and amount claimed.
4. Ensure that the calculation for the total claimed amount is accurate based on the installed mileage rate. For instance, use 23 cents per mile for 2015 or 19 cents per mile for 2016.
5. Read the Employee Statement carefully. After confirming that the information provided is accurate and that you have not received reimbursement from any other source for these expenses, sign and date the form.
6. Attach any necessary documentation that supports your claims, such as maps or mileage calculations. Ensure all required fields in the form are filled out correctly.
7. Mail or fax the completed form to the designated address or fax number provided, ensuring all documentation is enclosed.
8. Finally, save your changes, download a copy for your records, print the form, or share the form as needed.

Start filling out your FSA HRA Mileage Claim Form online today!