Health Reimbursement Account Document Archives | BRI

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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.