HRA/SRA Travel Attestation Form
Claim Form
To request reimbursement of eligible expenses.
PHI Authorization/Revocation Form
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.
