Get Hra_participation_agreement. Claim Form

Filling out the HRA_Participation_Agreement. Claim Form online is a straightforward process that ensures you access your health reimbursement account effectively. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to retrieve the form and open it in your preferred document editor.
2. Fill in the group information section with your employer group's name, the date, and the contact details of the plan administrator. Ensure accuracy to prevent delays in processing.
3. Provide the member HRA effective date and select the appropriate HRA coverage tier: Single, Family, or Employee + 1 (Child/Spouse). Enter the corresponding HRA coverage amount.
4. Indicate the member's date of hire or change of status. Enter the HRA plan year start and end dates accurately.
5. Answer whether there is an out-of-pocket deductible that must be met before the HRA funding is activated by selecting 'Yes' or 'No'. If 'Yes', include the necessary details.
6. In the individuals covered section, list all covered individuals, including their relationship to you, names, debit card preferences, dates of birth, social security numbers, mailing address, email, sex, and if applicable, Medicare claim numbers.
7. Review the member signature section carefully. Check the box affirming your understanding of the agreement and sign with the date.

Complete all necessary documents online to ensure a smooth and efficient process.