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WF HRA Claim Form11 4 2019 docx-2026
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- Click ‘Get Form’ to open the WF HRA Claim Form in the editor.
- Begin by filling out the MEMBER INFORMATION section. Enter your Social Security number, last name, first name, and other personal details as required.
- Proceed to the PATIENT INFORMATION section. If you are claiming for dependents, ensure to complete a separate form for each eligible dependent.
- In the CLAIM INFORMATION section, list each medical expense incurred. Attach itemized bills that include patient names, provider details, and dates of service.
- Calculate your total reimbursement amount by subtracting any health plan payments from the total charges incurred.
- Sign and date the form in the MEMBER SIGNATURE/CERTIFICATION FOR REIMBURSEMENT section to confirm accuracy and compliance.
- Finally, submit your completed form along with all necessary documentation to the specified address for processing.
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