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Forms for Health Reimbursement Accounts (HRA)

These PDF forms can be downloaded and printed.

Certification of Medical Necessity Form
To use for medical services/items that require additional documentation from a licensed health care provider (submit with your completed Claim Form).
 
Claim Form
To request reimbursement of eligible HRA expenses. (HRA expenses that were paid for with a Beniversal Card cannot be submitted for reimbursement.)
 
Direct Deposit Authorization Form
To set up new authorization of reimbursements to be deposited directly into your bank account or to change current direct deposit information.
 
Enrollment / Change Form
To enroll or report changes in your HRA Plan.
 
Medical Expense Worksheet
Extensive list of medical expenses that may be eligible under your HRA Plan.
 
Mileage Expense Certification Form
To provide supporting documentation when claiming mileage for eligible services from your HRA (submit with your completed Claim Form).

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