Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the Employee Information section. Fill in your Name, Social Security Number, Email Address, and Phone Number accurately.
3. Select one or both reimbursement codes by checking the appropriate box: 'H' for HRA Reimbursement Request or 'F' for Medical Expense/Flex Reimbursement Request.
4. In the subsequent fields, provide details about each expense. Enter the Code, Date of Service, Person Incurring Expense, Relationship to you, Provider name, Description of Service, and Amount Requested.
5. At the bottom of the form, indicate the Total Amount of Flex Reimbursement Requested and Total Amount of HRA Reimbursement Requested.
6. Review the certification statement regarding your expenses and check if there is a change of address. If applicable, provide your new address.
7. Finally, sign and date the form to complete your request for reimbursement.

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