Phone: (800) 473-9595 FSA/HRA 200-8 Website: www.BenefitResource.com FSA/HRA REIMBURSEMENT CLAIM FORM (Please Print Clearly) PART 1 PART 2 Check here if address has changed and provide new information below.
Medical expenses were incurred only for an
immediate medical purpose.
4.
For each item you are claiming in Part 3, you must attach a copy of itemized bills, statements, receipts or insurance company Explanation of Benefits (EOBs).
This
documentation from your provider mu...
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
EduTech School Districts 
