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).
| Over-The-Counter (OTC) Chart|
Sample chart of OTC items that may be eligible from your HRA. You should check your plan's documentation to see if OTC items are eligible under your plan.