Home
Forms Library
Health Reimbursement Account (HRA) Pay Me Back Claim Form

Health Reimbursement Account (HRA) Pay Me Back Claim Form 2025

Health Reimbursement Account (HRA) Pay Me Back Claim Form Preview on Page 1

See details

4.8 out of 5

47 votes

The document is a Health Reimbursement Account (HRA) Pay Me Back Claim Form provided by WageWorks. It outlines the process for account holders to request reimbursement for eligible medical expenses incurred by themselves or dependents. The form requires personal information, certification of accuracy, and detailed documentation of expenses, including receipts and proof of payment. Instructions are provided for completing the form and submitting claims, emphasizing the importance of accuracy and completeness to ensure timely processing.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Health Reimbursement Account (HRA) Pay Me Back Claim Form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the Health Reimbursement Account (HRA) Pay Me Back Claim Form in the editor.
Begin by filling out the 'Account Holder Information' section. Enter your last name, first name, and the last four digits of your Social Security Number. Include your employer's name and, if applicable, your spouse or survivor's SSN.
In the 'Certification and Authorization' section, ensure you sign and date the form. This signature certifies that all information provided is accurate and complete.
Proceed to Section 1 for SSA Deducted Premiums. Fill in the service start and end dates, annual out-of-pocket costs, and attach proof of payment such as a Social Security statement.
For Section 2 regarding Health Plan Premiums not deducted from Social Security, provide documentation showing coverage periods and proof of payment. Ensure you indicate service dates accurately.
Complete Section 3 for other expenses like co-pays or dental services. Attach itemized receipts for each expense claimed.
Review all sections for completeness before submitting. Make sure to keep copies of everything for your records.

Start using our platform today to easily fill out your HRA Pay Me Back Claim Form online for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How to fill a reimbursement claim form online?

How to submit reimbursement claims? STEP 1: Notify us in advance of your upcoming claim. STEP 2: Upload your documents online. STEP 3: Await confirmation on completeness of documents. STEP 4: Send hard copies of your claim documents.

How do I claim my reimbursement?

Ans: To claim reimbursement under your health insurance policy, you need to first inform your insurance company about the hospitalization within the specified timeframe and pay the hospital bills out-of-pocket at the time of discharge.

How to fill out a reimbursement form?

For the business to verify that the expense was actually work-related, its important to include all essential information about the expense on your reimbursement form: Name of product or service. Individual item or line cost. Total cost. Payment method (i.e., cash, credit card, etc.) Date purchased. Explanation of purchase.

How to claim reimbursement form?

Follow the steps given below to file a reimbursement health insurance claim: Step 1: Inform the Insurance Company. Step 2: Obtain Treatment. Step 3: Pay the Hospital Bill. Step 4: Collect All Your Documents. Step 5: Fill up the Claim Form. Step 6: Submit All Documents to the Insurance Company.

What is a disadvantage of a health reimbursement account?

If you leave the company or the job is terminated, the HRA money does not go with you. No Standardization Plan flexibility may be great for employers, but if your new employer offers different reimbursement rules than your previous one, it could be confusing.

How does WageWorks pay me back?

Through the WageWorks EZ Receipts mobile app. Use your mobile device to snap a photo of your receipts and submit them for reimbursement. Though your WageWorks account. Log into your account, select the Pay Me Back option, upload a digital image of your receipt, and submit your claim.

How to use a health care reimbursement account?

You can use the funds in your HRA to pay for eligible medical expenses, as determined by the IRS and your employer. Some employers may only allow the HRA to pay for services covered by your health plan.

How does claim reimbursement work?

What Is Reimbursement Claim in Health Insurance? Reimbursement claims are insurance claims wherein you pay for your hospital bills after your treatment and then submit the relevant documents to your insurance provider for a pay out as per the policy coverage.

Health Reimbursement Account (HRA) Pay Me Back Claim Form 2025

Here's how it works