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ELECTRONIC FORMS Simply click on the navigation link listed for the form you’re needing.  When the form comes up on your computer, simply fill in the requested fields.  Once complete, click the ”Send” button at the bottom of the form.

When submitting an Online Claim Form for your HRA, be sure to attach your supporting documentation.  IRS Acceptable forms of supporting documentation are the following:

  • Claims Itemization Summary Report from Moda, your Medical Insurance Carrier.

Note:  Estimates for services that have not yet been incurred CANNOT be accepted.

Note:  Be sure to keep a copy of your documentation on file at all times.

PDF "Fillable" Forms

NOTE: Please download the PDF forms to your computer before filling them out. Please be sure to follow instructions listed on the form. Please “Type ” your information into the form, making sure to complete each section in its entirety. Print, Sign, Date and submit your claim form and documentation by email to: or Fax to: (855-673-6711) to IntegraFlex. By doing so, you will ensure your submission is processed correctly and in a timely manner.

PDF "Fillable" Claim Forms:

HRA Claim