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 (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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