RHCA & HRA Claim Form - Chrysler Retirees 2026

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4.6 out of 5

39 votes

The document provides detailed instructions for filing claims related to Retiree Health Care Accounts (RHCA) and Health Retirement Accounts (HRA) through WageWorks. It outlines options for online, fax, or mail submissions, necessary documentation requirements, tips for successful claim submission, and definitions of eligible dependents. Additionally, it emphasizes the importance of accurate information and compliance with guidelines to ensure timely processing of claims.

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Click ‘Get Form’ to open the RHCA & HRA Claim Form in the editor.
Begin by filling out all account holder information, including your last name, first name, employer name (without abbreviation), and ID code (last 4 digits of SSN).
In the provider info section, enter the provider's name and service dates. Ensure that you have accurate documentation for these entries.
For each patient listed, provide their name, relationship to the account holder, and type of service received. This includes options like medical, vision, dental, etc.
Complete the claim form total by entering your out-of-pocket costs and selecting how you want your claim processed—either from your HRA or RHCA.
Finally, certify that all information is accurate by signing and dating the form before submitting it electronically or via fax/mail.

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Versions	Form popularity	Fillable & printable
2019	4.4 Satisfied (54 Votes)
2017	4.7 Satisfied (56 Votes)
2016	4.6 Satisfied (39 Votes)

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