WebMail (recommended) or fax completed forms to: Address: HealthEquity, Attn: Reimbursement Accounts. 15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020 ... some health care services and products are only eligible for reimbursement from your health care FSA, limited purpose FSA, and HRA when your doctor or other licensed health care … WebAn independent and FDIC-insured bank holds the health saving account dollars. Complete this form to receive reimbursement for money paid out-of-pocket for qualified medical expenses. Mail, email or fax the completed form to: Mail: CDH Administrator 15 West Scenic Pointe Drive, Suite 400 Draper, UT 84020 Email: reimbursementaccounts ...
Your HSA Reimbursement Cheat Sheet
WebThe annual limit for the Health Care Reimbursement Account is: January 1, 2024: $3,050. January 1, 2024: $2,850. By setting aside pre-tax money from your pay into the Health Care and/or the Dependent Care Reimbursement Account, you may later file for reimbursement of eligible expenses incurred in the plan year (Jan. 1 - Dec. 31) that are not ... WebApr 30, 2024 · Misplaced HSA Distribution Form: Apply this online form to report a mistakenly distribution from your HealthEquity Health Savings Account. HSA Reimbursement Form: Submit for reimbursements from yours Health Savings Account. ONE whole listing of section 213(d) proficient medical expenses canned being found at … different windows versions windows 10
Claim Filing Requirements - HealthEquity
WebDec 18, 2024 · General documentation requirements for FSA,HRA, and DCRA. Documentation must include all of the following: Name of patient. Provider. Service or item purchased. Service date (s) Dollar amount. You may also need to submit a letter of medical necessity for certain purchases. See qualified medical expenses for more information. WebHRA Reimbursement Form Mail or fax completed forms to: Address: HealthEquity, Attn: Reimbursement Accounts 15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020 Fax: 801.999.7829, cover sheet not required Account Holder Information Company Name Last 4 of SSN or HealthEquity ID Number (6 or 7 digits) Last Name First Name M.I. WebJun 16, 2024 · Otherwise, you may choose to download the paper form below. Complete a ' Return of reimbursement account overpayment form' (available from the 'Docs & Forms' tab of the member portal). Submit a receipt or Explanation of Benefits (EOB) for a different expense to offset the overpayment. Request that an unpaid claim (or multiple claims) in … forms to renew passport in person