718 223 4313-2026

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The document is a reimbursement guide for the Plumbers Local Union No.1 Welfare Fund's Health Reimbursement Arrangement (HRA) account. It outlines the process for filing claims for health care reimbursements, including eligibility criteria, required documentation, and specific expenses that can be submitted for reimbursement. The guide emphasizes the need for itemized bills, the minimum reimbursement amount of $25, and provides detailed instructions on how to complete the claim form. Additionally, it lists eligible and excluded expenses under the HRA.

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Click ‘Get Form’ to open the 718 223 4313 in the editor.
Begin by completing the personal information section on the Reimbursement Form, including your name, address, and social security number.
List each eligible expense in the designated fields and attach itemized bills for each expense. Ensure that these bills include necessary details such as provider name and date of service.
If any expenses are partially covered by a health plan, submit a copy of the Explanation of Benefits (EOB) along with your claim.
Calculate your net out-of-pocket expenses by subtracting any health plan payments from the total charges incurred.
Sign and date your reimbursement request before mailing it along with all documentation to the specified address.

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