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Forms/Health Reimbursement Account
If you have a login, you don’t need to download forms.

Get things done faster online.

  • Claim Form
    • To request reimbursement of eligible expenses.
  • PHI Authorization/Revocation Form
  • Over-The-Counter (OTC) Chart
    • Sample chart of OTC items that may be eligible from your HRA or FSA. You should check your plan’s documentation to see if OTC items are eligible under your plan.
  • Opt Out Form
    • To opt out of participating in your employer sponsored HRA.
  • Mileage Expense Certification Form
    • To provide supporting documentation when claiming mileage for eligible services from your pre-tax account.
  • Medical Expense Worksheet
    • Extensive list of medical expenses that may be eligible under your HRA Plan.
  • Enrollment/Change Form HRA
    • To enroll or report changes in your HRA Plan.
  • 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.
  • Certification of Medical Necessity Form
    • To use for medical services/items that require additional documentation from a licensed health care provider.

Benefit Resource, LLC

Simplifying the complexity of benefits for maximum savings and peace of mind.

Contact Information

245 Kenneth Drive
Rochester NY 14623-4277

email: info@benefitresource.com

phone: (866) 996-5200

fax: (585) 424-7273

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The Beniversal and eTRAC Prepaid Mastercards are issued by The Bancorp Bank pursuant to license by Mastercard International Incorporated. Mastercard is a registered
trademark, and the circles design is a trademark of, Mastercard International Incorporated. The Beniversal and eTRAC cards are accepted at qualified merchants accepting Debit
Mastercard. The Bancorp Bank; Member FDIC.

HSA Custodial Services are provided by a separate financial institution. See your HSA Account Agreement for specific account terms.

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