Health Reimbursement Account Claim Form

Health Reimbursement Account Claim Form
Submit your claim for eligible health expenses to your HRA administrator.
Claimant's Full Name
First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Service or Purchase
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Expense
Description of Expense (e.g., service received, item purchased)
Amount Claimed (USD)
Healthcare Provider or Merchant Name
Upload Supporting Documentation (receipts, invoices, EOB, etc.)
Cancelof
Do you have any additional comments or information regarding this claim?
Signature of Claimant
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