Health Reimbursement Arrangement (HRA) Claim Form
Employee Information
Employee Name
Employee ID
Employer Name
Address
City
State
Zip Code
Claim Details
Patient Name
Relationship to Employee
Self
Spouse
Child
Other
Date(s) of Service
Provider Name
Description of Service/Expense
Amount Requested
Other Relevant Details
Certification
I certify that the expenses listed above are eligible for reimbursement under my employer's HRA plan, have not been reimbursed, and will not be submitted for reimbursement elsewhere.
Employee Signature
Date