Fsa Hra Reimbursement Form printable pdf download

FSA/HRA Reimbursement Form

E-mail, mail, or fax completed forms to:

E-mail:

Address: HealthEquity, Att n: Reimbursement Accounts

For faster processing, upload completed forms

15 W Scenic Pointe Dr, Ste 400, Draper, UT 84020

and documentati on on your member portal.

Fax:

801.999.7829, cover sheet not required

Account Holder Informati on

Company Name

SSN or 6-Digit HealthEquity ID Number

Last Name

First Name

M.I.

Street Address

City

State

ZIP

E-Mail Address (required)

Dayti me Phone

Work Phone

(

)

(

)

FSA

HRA

Reimbursement Informati on



(required)

Pati ent Name

Service Provider

Date Incurred (Actual date[s] of service)

Start Date:

End Date:

Descripti on

Amount

Pati ent Name

Service Provider

Date Incurred (Actual date[s] of service)

Start Date:

End Date:

Descripti on

Amount

Pati ent Name

Service Provider

Date Incurred (Actual date[s] of service)

Start Date:

End Date:

Descripti on

Amount

Pati ent Name

Service Provider

Date Incurred (Actual date[s] of service)

Start Date:

End Date:

Descripti on

Amount

Pati ent Name

Service Provider

Date Incurred (Actual date[s] of service)

Start Date:

End Date:

Descripti on

Amount

Pati ent Name

Service Provider

Date Incurred (Actual date[s] of service)

Start Date:

End Date:

Descripti on

Amount

TOTAL AMOUNT REQUESTED

Account Holder Certi ﬁ cati on

By signing below, I request reimbursement for the qualiﬁ ed expenses listed above. I have att ached appropriate receipts or third-party proof that I

have incurred these expenses within the plan year and during the beneﬁ t period under this plan. I certi fy that I have not been reimbursed for these

expenses from insurance or from any other source. I understand that I cannot claim these expenses on my income tax return.

Account Holder Signature

Date

Note: Please att ach proper documentati on to this form. An explanati on of beneﬁ ts or itemized receipt is required. Documentati on must include the actual

date the expense was incurred, the name of the person for who the service was provided, the provider’s name, descripti on of service, and cost. If you have

additi onal expenses, please complete an additi onal form. Send only copies of receipts. Keep original receipts for your records.

Update: Eﬀ ecti ve Jan. 1, 2011, a prescripti on or lett er of medical necessity will be required for all medicinal over-the-counter items (i.e. aspirin).

Over-the-counter claims without a doctor’s note will be denied. A lett er of medical necessity form is available on your HealthEquity® memberportal.

Reimbursement requests can also be made online at

877.472.8632

RA_Reimbursement_Form_20110719