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Cigna hsa reimbursement form

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

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The Cigna Health Care Reimbursement Request Form is designed for individuals to request payment from their HSA, HRA, FSA, or other accounts. It requires complete and accurate information to ensure timely processing of claims. The document outlines necessary employee and patient details, the declaration of eligible expenses, and instructions for submitting receipts. Additionally, it includes FAQs regarding filling out the form, sending requests, and managing reimbursements.

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How to use or fill out 865625b Cigna HSA, HRA, and FSA Reimbursement Request Form. 865625b Interactive

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Click ‘Get Form’ to open it in the editor.
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.
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.
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.
Finally, sign and date the form in Box 18. Remember that unsigned forms will not be processed.

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