- Rev.
- 08/2011
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...
FLEX & HRA Claim Form 
