Get Hra Reimbursement Request Form Image - Amherst

The HRA Reimbursement Request Form is essential for users seeking reimbursement for eligible health expenses. This guide outlines each section and field of the form, ensuring a smooth completion process.

Follow the steps to successfully complete your HRA reimbursement request online.

1. Click ‘Get Form’ button to access the reimbursement request form and open it in your chosen editor.
2. In the Employee Information section, clearly print your name in the ‘Employee Name’ field, including your last name, first name, and middle initial. Input your employer's name and your Employee ID.
3. Fill out your home address, which includes your street, city, state, and zip code. Provide your email address and home and work phone numbers.
4. If requesting reimbursement for your spouse or dependent children, complete the Spouse and Dependent Information section. Include the dependent’s name, date of birth, relationship to you, and any relevant expenses.
5. List each allowable expense in the Expenses section. For each expense, provide a description, the date of service, and the amount incurred. Ensure that the total expenses are calculated correctly.
6. Attach the necessary Explanation of Benefits (EOB) statements that include details about the services received and proof of payment. Remember, do not submit canceled checks.
7. In the Employee Certification section, sign and date the form to certify that the information provided is accurate and complies with the relevant plan rules.
8. Once all sections are filled out, save your changes, download a copy of the form, print it if necessary, and securely share it as needed.

Complete your HRA reimbursement request online today for a smooth and efficient process.