Get the free FSA/HRA Reimbursement Form

This form is used to request reimbursement for qualified expenses incurred under a Flexible Spending Account (FSA) or Health Reimbursement Account (HRA).

How to fill out fsahra reimbursement form

How to fill out FSA/HRA Reimbursement Form

1. Obtain the FSA/HRA Reimbursement Form from your employer's HR department or website.
2. Fill in your personal information including your name, address, and contact details.
3. Provide your employee ID number or Social Security number as required.
4. List the expense details including date of service, description of the service, and amount incurred.
5. Attach any required documentation such as receipts or invoices as proof of the expenses.
6. Sign and date the form to certify that the information provided is accurate.
7. Submit the completed form and all attachments to the designated person or email specified by your employer.

Who needs FSA/HRA Reimbursement Form?

1. Employees who have eligible medical expenses and are enrolled in an FSA or HRA plan.
2. Individuals seeking reimbursement for out-of-pocket healthcare costs covered by their FSA/HRA.
3. Workers looking to utilize their flexible spending accounts for qualified medical expenses.

For pdfFiller’s FAQs

What is FSA/HRA Reimbursement Form?

The FSA/HRA Reimbursement Form is a document used by employees to request reimbursement for eligible out-of-pocket medical expenses from their Flexible Spending Account (FSA) or Health Reimbursement Account (HRA).

Who is required to file FSA/HRA Reimbursement Form?

Employees who have incurred eligible medical expenses and wish to be reimbursed from their FSA or HRA are required to file the FSA/HRA Reimbursement Form.

How to fill out FSA/HRA Reimbursement Form?

To fill out the FSA/HRA Reimbursement Form, employees should provide their personal information, the details of the medical expenses incurred, including the type of service, date of service, amount paid, and attach any required documentation, such as receipts.

What is the purpose of FSA/HRA Reimbursement Form?

The purpose of the FSA/HRA Reimbursement Form is to facilitate the process of obtaining reimbursement for eligible healthcare expenses covered by the employee's Flexible Spending Account or Health Reimbursement Account.

What information must be reported on FSA/HRA Reimbursement Form?

The FSA/HRA Reimbursement Form typically requires information such as the employee's name, address, and account number, details of the incurred expense (including the type and date of service), the amount being claimed, and any supporting documentation like receipts or invoices.