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.
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Line
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Provider Name
(Name of doctor, hospital,dentist,etc)
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Person
Receiving
Service
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Date(s)
Expense(s)
Incurred
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Expense Type
(check one)
Med Dent Misc
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Total Expenses
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Amount Paid by Insurance
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Amount Paid by
You
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1
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2
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3
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4
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5
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6
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7
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8
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Totals
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$
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$
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$
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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: ________________________________________________________
