UDrive HRA Claim Form

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THIS IS NOT A PRINTABLE FORM. If you would like a Printable/PDF Fillable version of this form click here.

INSTRUCTIONS: This form is used for electronic claims submission ONLY when you're able to attach your downloaded or scanned Explanation of Benefits (EOB) from your computer with the Browse buttons located within this electronic form. Failure to complete all of the "required" fields may result in your attachments being dropped and you may have to reattach them after you've completed all of the "required" fields. Once complete and your attachments have been uploaded, please scroll all the way to the bottom of this form and be sure to sign/date before clicking the "Send" button below.

** Indicates Required Fields.

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Employer Information
Employee Information

Note: Please provide us with your best contact number and email address, so we may contact you regarding your account, if needed.

Submission Documentation Guidelines for Health Reimbursement Arrangement (HRA)

Please Note: CLAIM ATTACHMENTS - Failure to follow these Guidelines will result in reimbursement delay or possible denial.

HRA REQUIREMENTS:

A Copy of the Explanation of Benefits (EOB) from your Medical Insurance Carrier MUST be submitted. Estimates for services that have not yet been incurred CANNOT be accepted.

Note: Please be clear with your claim submissions:

-Make sure your Explanation of Benefit (EOB) shows the Amounts that have been applied and billed are the same that you list on your HRA Claim Form. Meaning your EOB should match what you list on your HRA Claim Form for reimbursement. Varying amounts of the applied and billed ONLY slows down your claim reimbursement/submission.

-You can ONLY submit claims that have been INCURRED within your Current Plan Year. Claims incurred outside of your Plan Year ARE NOT eligible for reimbursement.

Claim 1

(e.g. Physician, Dentist Hospital, Pharmacy, Insurance Carrier, etc)

(e.g. Copay, Rx, Ortho, Insurance Premium, etc.)

Browse...

Maximum file size 10MB (pdf, jpg or jpeg formats only)

Claim 2

(e.g. Physician, Dentist Hospital, Pharmacy, Insurance Carrier, etc)

(e.g. Copay, Rx, Ortho, Insurance Premium, etc.)

Browse...

Maximum file size 10MB (pdf, jpg or jpeg formats only)

Claim 3

(e.g. Physician, Dentist Hospital, Pharmacy, Insurance Carrier, etc)

(e.g. Copay, Rx, Ortho, Insurance Premium, etc.)

Browse...

Maximum file size 10MB (pdf, jpg or jpeg formats only)

Claim 4

(e.g. Physician, Dentist Hospital, Pharmacy, Insurance Carrier, etc)

(e.g. Copay, Rx, Ortho, Insurance Premium, etc.)

Browse...

Maximum file size 10MB (pdf, jpg or jpeg formats only)

Claim 5

(e.g. Physician, Dentist Hospital, Pharmacy, Insurance Carrier, etc)

(e.g. Copay, Rx, Ortho, Insurance Premium, etc.)

Browse...

Maximum file size 10MB (pdf, jpg or jpeg formats only)

PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

I certify that I have actually incurred these eligible expenses. I understand that expense incurred means the service has been provided that gave rise to the expense, regardless of when I am billed, or charged for or pay for the service. The expenses have not been reimbursed or are not reimbursable from any other source. I understand that any amounts reimbursed may not be claimed on my or my spouse’s income tax returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions.

Scroll to bottom of form to "Send."

Date of Signature

REIMBURSEMENT INSTRUCTIONS

Once we receive your claim form and EOB, we’ll generate a reimbursement to you. For fastest reimbursement, we recommend signing up for Direct Deposit should your employer offer this option. If you have not already and would like Direct Deposit reimbursement, click here to sign up.

CLAIM SUBMISSION INSTRUCTIONS

Please refer to the HRA Claim Form under the Submission Guidelines section that lists the HRA Documentation Requirements that are “Acceptable” under the IRS Guidelines. Please follow these guidelines in order not to delay or possibly deny your claim submission.

Please be clear with your claim submissions:

a) Make sure your Explanation of Benefit (EOB) shows the Amounts Applied and Billed are the same that you list on your HRA Claim Form. Meaning your EOB should match what you list on your HRA Claim Form. Varying amounts applied and billed ONLY slows down your claim reimbursement submission.

b) You can ONLY submit claims that have been INCURRED within your Current Plan Year. Claims incurred outside of your Plan Year ARE NOT eligible for reimbursement.

Please be sure to list the amount you are requesting on your HRA Claim Form located under the Total amount requested from your HRA section of the claim form.

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