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
35