Y106 - Health Reimbursement Arrangement (Hra) Claim Form printable pdf download

Please attach documentation to the back of this form

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Health Reimbursement Arrangement (HRA) Claim Form

Name: __________________________________________________________ SS No: __________________________

Address: _________________________________________________________________________________________

City: _______________________________________ State: ______________ Zip Code: _________________________

ID No.: _____________________________________________ Phone No.: (_________) _________________________

E-mail Address:____________________________________________________________________________________

Please select the type(s) of refund you are utilizing, and then fill in all areas of that section.



1. Self Payment / Retiree Payment Reimbursements

Please fill month(s) of refund and dollar amount(s).

Claim Total:



2. Deductible, Coinsurance & other Eligible Reimbursements

(Must be submitted within 24 months of the date on which the expense was incurred in order to be eligible for reimbursement)

Please attach the Explanation of Benefits (EOB) in the order you have it listed below and fill in with dates of service, description, and claim total, then sign and date below and

mail or fax to Wilson-McShane Corporation, Attn: Operating Engineers #49 Claims Department

All valid forms of documentation must include the following: Date(s) of Service, Type of Expense, Amount Applied to the

Deductible and the Name of the Service Provider. See back of this form for a description of valid forms of documentation.

List each EOB separately

Date(s) of Service

Description

Dollar Amount

Claim Total:

This is to certify that my statements on this Claim Form are complete and true. I am claiming reimbursement only for eligible expenses incurred during the applicable

plan year and for my eligible dependents. I certify that these expenses have not been, nor will be reimbursed under this or any other benefit plan and will not be claimed

as an income tax deduction. I authorize my HRA account to be reduced by the amount requested.

Signature:_______________________________________________ Date:_______________________________

Reminders:

Sign and date the Reimbursement Form. Wilson-McShane Corporation cannot process an unsigned form.

Provide an EOB(s) for all expenses submitted. / Keep copies of everything submitted. / Minimum check amount is $25.00.

Cancelled checks or credit card receipts/statements or Provider statements are not valid forms of documentation.

IRS guidelines require that Wilson-McShane Corporation keeps records of all claims and correspondence for three years.

Multiple expenses may be included on one form. If more space is needed, attach additional forms.

Mail completed forms to:

Wilson-McShane Corporation

Attn: Operating Engineers #49 Claims Department

3001 Metro Drive - Suite 500, Bloomington, MN 55425

Phone: (952) 854-0795 Fax: (952) 851-3521

Y106

Y106 - Health Reimbursement Arrangement (Hra) Claim Form

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