Vision Care HSA Reimbursement Claim Form

Vision Care HSA Reimbursement Claim Form
Submit your claim for reimbursement of eligible vision care expenses using your HSA.
Claimant Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Member or Employee ID (if applicable)
Vision Care Provider Name
Date of Service
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Vision Service
Total Amount Paid (USD)
Upload Receipt or Proof of Payment
Cancelof
Additional Notes or Comments (optional)
Signature
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