Health Reimbursement Account (HRA) Claim Form (Retirees)Health Reimbursement Account (HRA) Claim For 2025

1. Click ‘Get Form’ to open the Health Reimbursement Account (HRA) Claim Form in the editor.
2. Begin by filling out Section 1: Your Information. Enter your Social Security Number or Employee ID, Company Name, Last Name, Home Zip Code, Email, and Daytime Phone Number using CAPITAL LETTERS.
3. Proceed to Section 2: Your Health Care Expenses. For each expense type (Medical, Prescription, Dental, Premium, Vision), indicate the service start and end dates in MM/DD/YY format and enter the amount of the claim submitted.
4. Attach necessary documentation such as an Explanation of Benefits or itemized invoices that include details like the date incurred, service provider name, description of service, and amount.
5. Complete Section 3: Certification by confirming that all information is accurate and that you have not previously received reimbursement for these expenses.

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