Deductible Reimbursement (HRA) Claim Forms (carrier specific)
HIGHMARK - HRA Claim Form (pdf)
UHC - HRA Claim Form (pdf)
UPMC - HRA Claim Form (pdf)
Flexible Spending Account (FSA) Reimbursement Claim Form (Medical and/or Dependent Care)
FSA Claim Form (pdf)
Summit FSA Claim Form (pdf)
Eligible or Ineligible Expenses under Medical FSA or HSA plans (not all inclusive)
Eligible-Ineligible Listing (pdf)
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