Medical Expense Flex & HRA Reimbursement Request Form 2026

1. Click ‘Get Form’ to open the Medical Expense Flex & HRA Reimbursement Request Form in the editor.
2. Begin by entering your Employee Information. Fill in your Name, Social Security Number, Email Address, and Phone Number accurately.
3. Select one or both reimbursement codes: 'H' for HRA REIMBURSEMENT REQUEST and 'F' for MEDICAL EXPENSE/FLEX REIMBURSEMENT REQUEST. Ensure you check the appropriate box.
4. In the documentation section, provide details such as Date of Service, Person Incurring Expense, Relationship to you, Provider name, Description of Service, and Amount Requested.
5. Calculate and enter the Total Amount of Flex Reimbursement Requested and Total Amount of HRA Reimbursement Requested.
6. Review the certification statements regarding your expenses and ensure you understand them before signing. Finally, add your Employee Signature and Date.

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