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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. |
| HRA Enrollment / Change Form To enroll and/or report changes in your HRA Plan. |
| HRA Enrollment / Change Form with Beniversal To enroll and/or report changes in your HRA Plan with the Beniversal Card. |
| HRA 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). |