865625b Cigna HSA, HRA, and FSA Reimbursement Request Form. 865625b Interactive 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Employee Information. Fill in your Cigna ID Number or Social Security Number, Last Name, First Name, Date of Birth, and Mailing Address. Ensure all fields marked with an asterisk (*) are completed.
3. Next, provide Patient Information. Enter the Patient's Name, Birth Date, Service Begin Date, and the Amount Requested for Reimbursement. Attach any necessary receipts or Explanation of Benefits.
4. In the Type of Service or Purchase section, specify what services were rendered. Include Procedure Code or Description of Service and the name of the Health Care Professional or Facility.
5. Finally, sign and date the form in Box 18. Remember that unsigned forms will not be processed.

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