Get the free FSA-HRA Claim Form - The Walsh Group

FSA/HRA Claim Form Company Name: Please mail claims to: The Walsh Group Attn: FSA Administration 3638 Seneca Street Phone: (716) 6752100 Ext 19 West Seneca, NY 14224 Fax: (716) 6754956 Complete sections

How to fill out fsa-hra claim form

How to fill out fsa-hra claim form?

1. Gather necessary information: Before you start filling out the fsa-hra claim form, gather all the required information. This may include your personal details, such as your name, address, and social security number, as well as relevant information about the expense you are claiming.
2. Start with the basic details: Begin filling out the form by providing your basic information, such as your name, address, and contact information. Ensure that all the information is accurate and up-to-date.
3. Indicate the type of claim: Specify whether you are submitting a claim for a Flexible Spending Account (FSA) or a Health Reimbursement Arrangement (HRA). Make sure to check the appropriate box to avoid any confusion.
4. Provide details of the expense: In this section, you will need to provide detailed information about the expense you are claiming. Include the date of the expense, the provider's name, a description of the service or product, and the amount you paid. It's important to keep any supporting documentation, such as receipts or invoices, for future reference.
5. Submit any required documentation: Depending on the type of expense you are claiming, you may need to submit additional documents to support your claim. These can include medical bills, pharmacy receipts, or an itemized statement. Make sure to attach these documents securely to the claim form.
6. Review and sign the form: Before submitting the form, carefully review all the information you have provided to ensure accuracy. Once you are satisfied, sign and date the form. Your signature confirms that all the information you have provided is true and accurate to the best of your knowledge.

Who needs fsa-hra claim form?

1. Employees with a Flexible Spending Account (FSA): If you participate in a company-sponsored FSA, you will need to fill out the fsa-hra claim form to request reimbursement for eligible expenses. The FSA allows you to set aside pre-tax money from your paycheck to pay for qualified medical expenses.
2. Individuals with a Health Reimbursement Arrangement (HRA): Those who have an HRA provided by their employer will also need to complete the fsa-hra claim form. An HRA is an employer-funded account that reimburses employees for eligible medical expenses.
3. Participants in both FSA and HRA: In some cases, individuals may have both an FSA and an HRA. If this applies to you, you will need to fill out the fsa-hra claim form to request reimbursement from both accounts separately.

Remember, it's essential to follow the specific guidelines and instructions provided by your employer or benefits administrator when filling out the fsa-hra claim form.

For pdfFiller’s FAQs

What is fsa-hra claim form?

The fsa-hra claim form is a document used to request reimbursement for qualified medical expenses incurred under a flexible spending account (FSA) or a health reimbursement arrangement (HRA).

Who is required to file fsa-hra claim form?

Employees who have participated in a FSA or HRA program and have incurred eligible medical expenses are required to file a fsa-hra claim form.

How to fill out fsa-hra claim form?

To fill out a fsa-hra claim form, employees need to provide details of the medical expenses incurred, including dates of service, description of the expenses, and the total amount being claimed.

What is the purpose of fsa-hra claim form?

The purpose of the fsa-hra claim form is to request reimbursement for eligible medical expenses in accordance with the rules of the FSA or HRA program.

What information must be reported on fsa-hra claim form?

The fsa-hra claim form must include information such as the name of the employee, dates of service for the medical expenses, description of the expenses, total amount claimed, and any supporting documentation.

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