Get Ny Plumbers Local Union 1 Health Reimbursement Arrangement (hra) Claim Request Form 2019-2025

This guide provides detailed, step-by-step instructions on completing the NY Plumbers Local Union 1 Health Reimbursement Arrangement (HRA) Claim Request Form online. By following these instructions, users can efficiently and effectively submit their claims for reimbursement of eligible medical expenses.

Follow the steps to complete the HRA Claim Request Form online.

1. Press the 'Get Form' button to access and open the HRA Claim Request Form in your online editor.
2. Begin by filling in the member information section (Part A). Complete items 1 through 13, including details such as your social security number, last name, first name, initial, address, city, state, ZIP code, birth date, and daytime telephone numbers.
3. Move to Part B to provide patient information. Complete items 14 through 22. If there are multiple eligible dependents, remember to use a separate form for each one.
4. In Part C, list each expense incurred. For each expense, provide the type (MD, RX, OTC, etc.), date of service, provider name, charges incurred, health plan payment, and net out-of-pocket expenses. Make sure to attach itemized bills for each expense.
5. Review and calculate the total reimbursement requested at the end of Part C, ensuring that all amounts are correct.
6. Proceed to the member signature section (Part D). Read the certification statement carefully, then sign and date the form to confirm the accuracy of the information provided.
7. Finalize your submission by mailing the completed form and attached documentation to the specified address: Plumbers Local Union No. 1 Welfare Fund, 50-02 5th Street, Long Island City, NY 11101.

Complete your HRA Claim Request Form online today to ensure a smooth reimbursement process.