Reimbursement account request 2026

1. Click ‘Get Form’ to open the reimbursement account request in the editor.
2. Begin by filling out Section B, Employee Information. Enter your identification number, plan year, employer details, and contact information accurately.
3. In Section C, Health Care Expenses, list each service date and provider name. Specify the type of service (e.g., copayment or prescription) and enter the amount requested for each expense.
4. Ensure you total all amounts in Section C and check if any amounts offset previous transactions before submitting.
5. In Section D, Certification, read through the conditions carefully. Sign and date the form to confirm your understanding and compliance.
6. Attach all required supporting documentation as outlined in the instructions. This includes itemized bills and explanation of benefits (EOB).

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