Request Reimbursement From an HRA or FSA

Do you have a flexible spending account (FSA) or health reimbursement account (HRA)? These accounts can reimburse you for expenses your health plan doesn’t cover. Use the forms in this section to request reimbursement.

FSA forms

FSAs allow you to put money aside, tax-free, for certain types of medical expenses. Use these forms to request reimbursement from your account.

Medical Reimbursement FSA Claim Form Qualified Transportation Account Claim Form

A separate type of FSA allows you to set aside FSA funds for dependent care expenses, such as daycare fees. If you have this type of FSA, use this form to request reimbursement:

Dependent Care FSA Claim Form

HRA form

An HRA is an account your employer sets up and funds for you. Your employer owns the HRA and makes rules for how it works. Use this form to request reimbursement from your HRA:

HRA Claim Form