Get the free HRA Reimbursement Form - Employee Benefits Agency

Health Reimbursement Account Claim Form Fax Claims to: (855) 306-1098 Attn: TPA Claims Dept. or email to: claims cicbcg.com Total Pages:. Company Name Employee Name (Please Print or Type) Social Security

How to fill out hra reimbursement form

How to fill out hra reimbursement form:

1. Obtain the hra reimbursement form from your human resources department or employer.
2. Read the instructions carefully to understand the requirements and documentation needed.
3. Fill in your personal information accurately, including your name, address, and employee identification number.
4. Provide details of the expenses you are seeking reimbursement for, such as medical bills or rent receipts.
5. Attach any supporting documents, such as copies of bills or receipts, that validate your expenses.
6. Calculate the total amount you are requesting for reimbursement and enter it in the appropriate section.
7. Sign and date the form to certify the information provided is accurate.
8. Submit the completed form and all supporting documents to the designated authority or department.

Who needs hra reimbursement form:

1. Employees who have enrolled in a Health Reimbursement Arrangement (HRA) program offered by their employer.
2. Individuals who have incurred eligible healthcare or housing expenses that are covered by the HRA.
3. Individuals who wish to receive reimbursement for their eligible expenses through the HRA program provided by their employer.

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