Hra verification form 2026

1. Click ‘Get Form’ to open the hra verification form in the editor.
2. Begin by filling out the Enrollee Information section. Enter your last name, first name, primary phone number, secondary phone number, People First ID, date of birth, street address, city, state, and zip code. Ensure all information is printed clearly.
3. Attach a copy of your Explanation of Benefits (EOB) from your health insurance plan. This document must show that you have met the IRS-mandated deductible and include necessary details such as dates of service and amounts paid by insurance.
4. Indicate your health insurance plan coverage level by checking either 'Single' or 'Family'. Provide the date range of services covered by your deductible.
5. Complete the Deductible Amount Paid and Date Deductible Met fields accurately.
6. Sign and date the certification section to confirm that all provided information is accurate.
7. Finally, submit this form along with your EOB via fax or mail to Chard Snyder as instructed on the form.

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