Reimbursement Request Form

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H
HRA Reimbursement Request
PLEASE PRINT CLEARLY
CROSBY BENEFIT SYSTEMS
Employee
Information
Employee Name _____________________________________________________________________
Last
First
MI
To update your address
or email, please login to
Employer __________________________________________________________________________
Please enter your SSN or Employee ID. Many employers use an
Please also notify
SSN / Employee ID _____________________________
ID other than SSN with Crosby Benefit Systems. If you are unsure
employer of any
which number to use, please contact us or your HR/Benefits
address changes.
department. If you do not enter an SSN/Employee ID, Crosby will
attempt to identify you based on other information but this could
delay or prevent processing of your request.
Home Address _______________________________________________________________________
Street
City
State
Zip
Email Address _____________________________________
Home Phone (______)_____________________ Work Phone (______)_______________________
area code
area code
ext.
Expenses
Please list the allowable expenses and include the EOB statement stating the partial payment of the expense.
*
Description of Expense
Date of Service
Amount
To file a request for
_______________________________________________
______________
____________
reimbursement:
1. Complete an HRA
Reimbursement request
_______________________________________________
______________
____________
form.
2. Attach the
Explanation of Benefits
_______________________________________________
______________
____________
(EOB) statement.
Your proof for medical
_______________________________________________
______________
____________
expenses must clearly
indicate:
_______________________________________________
______________
____________
1. The person receiving
the service
2. The type of service
_______________________________________________
______________
____________
or supply
3. The name of the
person providing the
_______________________________________________
______________
____________
service or supply
4. The amount charged
_______________________________________________
______________
____________
5. The date the service
was rendered.
*
Do not include amounts paid or eligible for payment under any other
TOTAL EXPENSES
$____________
health care plan or program, federal, state or governmental
program, Workers’ Compensation, or any other policy of health
insurance.
Submit EOB statements with this form, showing the service or product provided, to whom, by
Whom, the date and the out-of-pocket expense. Retain a copy for your records. Canceled checks are NOT
acceptable. Neglecting to submit required documentation may delay claims processing.
Employee
By submitting this form, I hereby certify that all items submitted for reimbursement under the HRA plan comply with the
Certification
Reimbursement Plan rules and such items have not and will not be covered by any other plan of any employer or any other person. I
further certify that such items will not be deducted or taken as tax credits on my personal federal and/or state income tax return for any
year. My employer does not accept responsibility for direct payment to any individuals other than the employee. I have read and
Please
understand the information on the reverse side (or page 2) of this form.
SIGN
I have read and understand both the information on the reverse side (or page 2) of this form and the fact that I can request a copy of
the SPD from the Employer if I do not currently have a copy.
Employee Signature _________________________________________ Date __________________
Crosby Benefit Systems –866-918-9711 –Fax: 978-367-9626
P.O. Box 25172, Lehigh Valley, PA 18002-5172 - - version 0115

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