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Fax to: ASIFlex (877) 879-9038 *No Cover Page Required* HRA CLAIM FORM Last Name, First Name, MI (Please Print) Street Address Page 1 of Social Security Number City, State, Zip Health Reimbursement.

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An HRA is a specific type of fund account that can be combined with a health care plan to allow you to be reimbursed for certain out-of-pocket medical expenses. Your employer allocates a set amount of money to your account, and you can use this money to pay for eligible expenses.

2:05 3:19 How to Complete the HRA Application Form - YouTube YouTube Start of suggested clip End of suggested clip Information for your dependent that includes their name their gender their social security numberMoreInformation for your dependent that includes their name their gender their social security number and date of birth. What their relation is to you. And if that dependent is a medicare beneficiary.

Approved requests are paid once a week. Employees are typically reimbursed from their HRA within 10 to 14 days. If the request is held or denied, we'll notify the employee via email or letter.

You can submit your claim to ASIFlex by: Uploading your request through ASIFlex's secure online portal. The online portal is the fastest and easiest way to submit your claim. ... Toll-free fax: 1-877-879-9038. Mail: PO Box 6044, Columbia, MO 65205-6044.

How do I access my HRA money? You won't do anything — most plans will reimburse your network doctor directly. You'll use a debit card tied to the account, if offered by your employer. You'll pay for expenses up front, then request reimbursement.

Your employer contributes a certain amount to the HRA. You use the money to pay for qualifying medical expenses. For some types of HRA, you can also use the money to pay monthly premiums for a health plan you buy yourself.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232