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Forms for Health Reimbursement Accounts (HRA)
These PDF forms can be downloaded and printed.
| Certification of Medical Necessity For 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 expenses that were not purchased with a Beniversal Card. | |
| Direct Deposit Reimbursement Authorization To authorize reimbursements to be deposited directly into your bank account. | |
| Enrollment / Change Forms To enroll and/or report changes in your HRA Plan. | |
| Use if your Plan does not feature the Beniversal Card. | |
| Use if your plan year began on or before March 1, 2010 and features the Beniversal Card. | |
| Use if your plan year began on or after April 1, 2010 (or does not feature the Beniversal Card). | |
| Medical Expense Worksheet Extensive list of expenses that may be eligible under your HRA Plan. | |
| Mileage Expense Certification Log To provide supporting documentation when claiming mileage for eligible services (submit with your completed Claim Form). | |