HRA Carrier Claim Forms

Deductible Reimbursement (HRA) Claim Forms (carrier specific)

HIGHMARK - HRA Claim Form (pdf)

UHC - HRA Claim Form (pdf)

UPMC - HRA Claim Form (pdf)

CHR Flexible Spending Account (FSA) Claim Form

Flexible Spending Account (FSA) Reimbursement Claim Form (Medical and/or Dependent Care)

FSA Claim Form MED+DCAP (pdf)

Eligible or Ineligible Expenses under Medical FSA or HSA plans (not all inclusive)

Eligible-Ineligible_Jan 2022 (pdf)

This website uses cookies. By continuing to use this site, you accept our use of cookies.