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Medical Expense Flex & HRA Reimbursement Request Form 2026
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- Click ‘Get Form’ to open the Medical Expense Flex & HRA Reimbursement Request Form in the editor.
- Begin by entering your Employee Information. Fill in your Name, Social Security Number, Email Address, and Phone Number accurately.
- 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.
- 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.
- Calculate and enter the Total Amount of Flex Reimbursement Requested and Total Amount of HRA Reimbursement Requested.
- 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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Related links
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