Follow the steps to complete your claim form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Enter your participant information, including your name, address, city, state, zip code, telephone number, and email address.
3. Indicate how you prefer to receive your reimbursement check by checking either 'Mail' or 'Pick-up at Fund Office' (Fridays only between 12:00 PM and 4:00 PM, with a Member Photo I.D. required).
4. List the details of the medical expenses in the HRA Account Expense Claims section. Include the date the expense was incurred, the service provider's name, a brief description of the expense, the name of the person for whom the expense was incurred, and the expense amount.
5. Ensure that your total claim amount is calculated at the bottom of the expense claims section. Please note that your claim must total a minimum of $20.
6. Sign the authorization section to certify that the expenses were incurred while covered under the plan and that you are responsible for their accuracy.
7. Include the date of your signature.
8. Attach appropriate proof of payment for each listed expense, ensuring you follow the guidelines for acceptable documentation.
9. Once your claim form is fully completed and verified, you may save, download, print, or share the form as needed before submitting it.

Complete your document online today to ensure your health care expenses are reimbursed promptly.