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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).

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