HRA Claim Forms

 

HEALTH REIMBURSEMENT ACCOUNT CLAIM FORM
 
Employer: ____________________________________________ Phone Number: _(       )_____________________
 
Name: _____________________________________________________ SSN: _____________________________
 
Address: ______________________________________________________________________________________
                         Number and Street                                                                                     City, State, Zip
 
TO CLAIM REIMBURSEMENT ON ELIGIBLE EXPENSES
Submit documentation that clearly gives the following information:
  • Name of person receiving service
  • Description of service or supplies
  • Name of provider
  • Amount charged
  • Date service was rendered (not date paid)
  • Payments made by insurance
  • Evidence that payment has been made by the claimant
 
NOTE: MEDICAL/DENTAL EXPENSES Medical/Dental expenses covered under an insurance plan should be
            submitted to the insurance carrier first.   
     HEALTH/DENTAL DEDUCTIBLES Submitting a copy of the Explanation of Benefits forms received
     from your health or dental insurance will satisfy the above requirements.
 
Fill in the lines below, sign your name and attach all required documentation.
Label documentation to correspond with the appropriate line number.
Keep a copy and mail the original, with all documentation to:
                        FORMULA CORPORATION
                        HRA Claims
                        2919 Eagandale Blvd #120
                        Eagan, MN 55121-4203
 
For any questions, call: (651)686-0108 EXT 106, 1-888-686-0412 EXT 106 KELLIE B.
 
 
Line
Provider Name
(Name of doctor, hospital,dentist,etc)
Person
Receiving
Service
Date(s)
Expense(s)
Incurred
Expense Type
 (check one)
Med     Dent    Misc
 
Total Expenses
Amount Paid by Insurance
Amount Paid by
 You
 
1
 
 
 
    
 
 
 
 
 
 
2
 
 
 
 
 
 
 
 
 
 
3
 
 
 
 
 
 
 
 
 
 
4
 
 
 
 
 
 
 
 
 
 
5
 
 
 
 
 
 
 
 
 
 
6
 
 
 
 
 
 
 
 
 
 
7
 
 
 
 
 
 
 
 
 
 
8
 
 
 
 
 
 
 
 
 
 
 
Totals
 
$
 
$
 
$
 
I hereby certify that the information shown above is true and correct, and that neither I, my spouse, nor any of my eligible dependents have or will receive reimbursement for any of the expenses listed above from any other source, and furthermore, that I have not, and will not, claim any of these expenses as a deduction on, or in calculating a credit from my/my spouse’s income taxes. In addition, I certify that the “Person Receiving Service” listed above is eligible to be covered under the Plan.
 
Date: ________________________      Signed: ________________________________________________________
Site union-made by:
Union built by Prometheus Labor Prometheus Labor Union Websites