HRA Claim Form
For more information or tips about claim submissions or reimbursements, please go to this webpage.
Account Holder Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company/Employer name
Job Position/Title
Details about the claim
Rows
Date of Service
Covered Person Name
Relationship
Health Care Provider Name
Expense Description
Requested Amount
1
2
3
4
5
6
7
8
Total Requested Amount
Acknowledgment
I confirmed that all expenses for reimbursement are claimed through this form submission by me or an eligible person.
I understand that the claim will only be processed once completed, approved, and signed.
I confirmed that all information in this form is accurate and true to the best of my knowledge.
I authorized this institution to collect sensitive information.
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: