Return to flip book view

HRA REIMBURSEMENT REQUEST Please mail or fax your claims with this cover sheet to: OneDigital 180 Swinderman Rd., Suite 400, Wexford, PA 15090 Fax: 724.934.2339 / Telephone: 724.935.2310 EMPLOYER: Richmond Montessori School GROUP NUMBER: RMS101 Number of Pages (including receipts): EMPLOYEE NAME: Last Four Digits of SSN: YOUR ADDRESS: Please check if this is a change in address since you last submitted a claim. Street City State Zip Email Address Fax Number (for return correspondence) Home Phone Work Phone Please include your medical insurance carriers Explanation of Benefits (EOBs) for medical service claims. This is required in order to be reimbursed. HEALTH CARE ACCOUNT EXPENSES If a health care charge is eligible for full or partial reimbursement from an insurance carrier, the charge must be submitted to all applicable insurance carriers before this plan can make payment. Once the claim has been processed by your insurance carrier, attach your Explanation of Benefits statement (EOB) with an itemized receipt. If the charge does not need to be submitted to the insurance carrier (office visit copays, prescription copays, eligible over-the-counter drugs, etc.) attach your itemized receipt. Do not attach checks or credit card receipts, as the IRS does not recognize these items as valid receipts for this program. DATE OF SERVICE NAME OF SERVICE PROVIDER EXPENSE DESCRIPTION RECIPIENT OF SERVICE RELATIONSHIP TO EMPLOYEE NET AMOUNT / / $ / / $ / / $ / / $ / / $ / / $ / / $ / / $ Total (required): $ To the best of my knowledge and belief, my statements in this Request for Reimbursement are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable plan year and for eligible plan participants. I certify that these expenses have not been previously reimbursed under this or any other benefit plan, and will not be claimed as an income tax deduction. EMPLOYEE SIGNATURE (Required) DATE