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. | |