Get the free FSA/HRA Reimbursement Form

Instructions for submitting claims for reimbursement of healthcare expenses, outlining required documentation and processes for FSA and HRA claims.

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 their website.
2. Fill out your personal information at the top of the form including your name, address, and employee ID.
3. Specify the date of service for the expense you're claiming.
4. List the type of expense (e.g., medical, dental, vision) in the designated sections.
5. Enter the total amount you are claiming for reimbursement.
6. Attach any required documentation, such as receipts or invoices, that support your claim.
7. Review the form for accuracy and completeness.
8. Sign and date the form to certify the information is correct.
9. Submit the completed form and attachments via the specified method (mail, email, or online submission) to the appropriate department.

Who needs FSA/HRA Reimbursement Form?

1. Employees enrolled in a Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA) who want to claim reimbursement for eligible medical expenses.

For pdfFiller’s FAQs

What is FSA/HRA Reimbursement Form?

The FSA/HRA Reimbursement Form is a document that employees use to request reimbursement for eligible medical expenses paid with personal funds, using funds from their Flexible Spending Account (FSA) or Health Reimbursement Arrangement (HRA).

Who is required to file FSA/HRA Reimbursement Form?

Employees who have incurred eligible medical expenses and wish to receive reimbursement 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, you need to provide your personal information, itemize your eligible expenses, attach appropriate documentation for each expense, and sign the form certifying that the expenses are eligible for reimbursement.

What is the purpose of FSA/HRA Reimbursement Form?

The purpose of the FSA/HRA Reimbursement Form is to facilitate the process of requesting and obtaining reimbursement for out-of-pocket medical expenses that qualify under IRS guidelines from funds set aside in an FSA or HRA.

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

The information that must be reported on the FSA/HRA Reimbursement Form includes the employee's name, contact information, the type and amount of expenses being claimed, the date the expenses were incurred, and any required receipts or documentation demonstrating that the expenses are eligible for reimbursement.