Unified Fire Authority
COMPANY NAME : ______________________ _________________________________________ HRA REIMBURSEMENT FORM Benefits )
Return this form to : APA Benefits , Inc . 8899 S 700 E , Suite 225 Sandy , UT 84070 Fax : 801.561.5056 Email : claims @ apabenefits . com SECURE UPLOAD : via https :// apabenefits . lh1ondemand . com
Please attach EOB ( Explanation of
Participant Name Social Security Number
I hereby request reimbursement for the following expenses : NOTE : Federal law requires that in order for this claim to be adjudicated that proof of payment or a receipt is provided .
Date Name Provider Description Amount $ $ $ $ $ $ $ $ $
Total $
READ CAREFULLY Please attach a copy of all supporting documentation . Undocumented claims will not be processed . The Plan Administrator may request that you provide additional documentation before any claim is paid .
I certify that the information provided above is true and complete and that the expenses : ( i ) were incurred while I was a participant in the Plan , ( ii ) are not attributable to a deduction allowed under Code section 105 for any prior taxable year , and ( iii ) are not covered , paid or reimbursed from any other source .
Participant ’ s Signature Date
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