PRINTABLE FORMS

This page provides to you the necessary forms for completing 

Carrier HRA Claim Forms or CHR FSA Reimbursement Claim Forms.  

In addition, we may provide applicable references as we deem necessary.  


Please reach out to our office should you feel there is a form that may need added, updated or reviewed and we would be happy to go over the document with you.

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HRA Carrier Claim Forms

Below you will find carrier specific Request for Deductible Reimbursement (HRA) Claim Forms.  

 Please see the directions on the form on how to submit. 

HRA CLAIM FORM-HIGHMARK-Fillable (pdf)

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HRA CLAIM FORM-UnitedHealthcare-Fillable (pdf)

Download

HRA CLAIM FORM-UPMC-Fillable (pdf)

Download

CHR Flexible Spending Account (FSA) Reimbursement Claim Form

Use the below C.H. Reams Flexible Spending Account (FSA) Reimbursement Claim Form when submitting for FSA reimbursement.  Please see the directions on the form on how to submit.

FSA Claim Form MED+DCAP 2019-Fillable (pdf)

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FSA/HSA Eligible & Non-Eligible List

The below is a helpful reference on what may be a Eligible or a Non-Eligible Expense under a FSA or HSA plan.

FSA_HSA_Eligible_Ineligible_List_2019 (pdf)

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