For Employees

HRA Consolidated Claim Form

The HRA Consolidated Claim Form allows you to submit a one-time HRA reimbursement request or a recurring HRA reimbursement request, such as an insurance premium. 

HRA / FSA Consolidated Claim Form

The HRA / FSA Consolidated Claim Form allows you to submit a one-time HRA reimbursement request or a recurring HRA reimbursement request, such as an insurance premium. This form also allows you to submit reimbursement requests for FSA expenses and Dependent Care expenses.

HRA / FSA Consolidated Claim Form for Pennsylvania 

The HRA / FSA Consolidated Claim Form for Pennsylvania allows you to submit a one-time HRA reimbursement request or a recurring HRA reimbursement request, such as an insurance premium. This form also allows you to submit reimbursement requests for FSA expenses and Dependent Care expenses. This form also includes a section for premium assistance from PSERS, which is specific to the state of Pennsylvania.

FSA_HRA Restriction_Suspension Form

The FSA / HRA Restriction / Suspension Form allows you to restrict your FSA / HRA (or suspend, if appropriate) if you, your spouse, and / or eligible dependents are contributing to a Health Savings Account (HSA), or if you want to qualify for a subsidy on the exchange.

HRA Authorization for Release of PHI

The HRA Authorization for Release of PHI allows you to authorize certain individuals to receive information on your claims, payment, and other related health information about you. The form also includes an option that prohibits any type of disclosure to anyone other than yourself.

HRA Direct Deposit Form

The HRA Direct Deposit Form allows you to request that your reimbursements be directly deposited into your bank account. You may also use this form to change your current direct deposit information, or cancel your direct deposit.

HRA FSA Statement of Medical Necessity Form

The HRA / FSA Statement of Medical Necessity Form is signed by your doctor and shows that the service you received is medically necessary. Common services that require this form include: counseling, physical / occupation / massage therapy, and acne treatment.

HRA Attestation Form

The HRA Attestation Form allows you to attest to your recurring insurance premium claim each month. This form states that the insurance policy is still in effect and that the premium amount has not changed.

HRA Partial 213d Eligible / Ineligible List

The HRA Partial 213d Eligible / Ineligible List  provides common examples of eligible and ineligible HRA expenses.

Questions on HRA / FSA reimbursement documentation requirements? Check out our Documentation FAQs.

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