Get Mn Cds Medical Expense Flex & Hra Reimbursement Request Form 2019-2026

This guide provides clear instructions on how to accurately fill out the MN CDS Medical Expense Flex & HRA Reimbursement Request Form online. Follow these steps to ensure your reimbursement request is submitted correctly and efficiently.

Follow the steps to complete your reimbursement request form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your employee information by entering your name, social security number, email address, and phone number. Ensure all information is accurate.
3. Indicate the type of reimbursement request by entering one or both codes below in the designated field: 'H' for HRA reimbursement request and 'F' for medical expense/flex reimbursement request.
4. Attach documentation related to the claim, confirming that it was submitted at www.cdsatpa.com, if applicable.
5. Enter the date of service for the expenses incurred.
6. Include the name of the person incurring the expense, their relationship to you, along with the provider's details.
7. Provide a description of the service received and the amount requested for reimbursement.
8. If applicable, fill in the total amount of flex reimbursement requested and the total amount of HRA reimbursement requested.
9. Read the certification statement carefully, affirming that the expenses are eligible and have not been reimbursed from other sources.
10. Sign and date the form to certify the accuracy of the information provided. If there’s a change of address, indicate this in the provided section.
11. Once all sections are completed, proceed to save changes, download, print, or share the completed form as necessary.

Complete your MN CDS Medical Expense Flex & HRA Reimbursement Request Form online today for a smooth reimbursement process.