FSA HRA Reimbursement Form - HealthEquity 2025

1. Click ‘Get Form’ to open the FSA HRA Reimbursement Form in the editor.
2. Begin by filling out the Participant Information section. Enter your Company Name, Employee Social Security Number, Last Name, First Name, and Middle Initial. Ensure your contact details such as Street Address, City, State, Zip Code, Email Address, Home Phone Number, and Work Phone Number are accurate.
3. In the Healthcare Reimbursement section, list each incurred expense. For each entry, provide the Date Incurred, Patient Name (mandatory), Service Provider name, Description of service provided, and Amount. Remember that claims will be denied without a patient name on supporting documents.
4. For Dependent Care Reimbursement, include the required information such as Date Incurred and Service Provider details. Ensure your provider signs in the designated area unless you attach an itemized receipt.
5. Complete the Certification section by signing and dating it to confirm that all expenses listed are valid and have not been reimbursed elsewhere.
6. Finally, attach any necessary documentation before submitting your form via mail, fax or email as indicated at the top of the form.

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