Claim Form Hv01 – Fill Out and Use This PDF

Have you previously separated or retired from the employer that made/is making contributions to this account?

Check here if your phone number, email, or mailing address has changed. Please provide updates below:

E-Communication:

Please check the box and enter your email address in the update box at the

left to receive e-statement notiications, newsletters, EOBs, and notices by email. Read details on reverse.

3PATIENT INFORMATION (covered individual)

LAST NAME

THIS INFORMATION IS REQUIRED BY FEDERAL LAW:

NAME EXACTLY AS IT APPEARS ON SOCIAL SECURITY CARD or MEDICARE CARD

1

2

3

4

HAVE MORE EXPENSES? Include an itemized list on a separate sheet of paper.

Please add up your expenses to verify the total.

Total Reimbursement Request

$

$

$

$

$

Submit proof of expense

Make sure you atach proof of each expense. Missing, incomplete, or illegible forms of documentaion are the most common reasons claims are denied. You can help avoid denied claims by making sure the proof you submit is legible and contains all of the following:

1.Name of covered individual who received the item or service;

2.Date item was purchased or service was provided;

3.Service Provider name (e.g. doctor, pharmacy, hospital, etc.);

4.Descripion of the item purchased or service received; and

5.Amount of out-of-pocket expense.

Cancelled checks, carbon copy checks, credit or debit card receipts, bank statements and balance forward or payment on account statements are not acceptable. Proper proof includes:

1.Explanaion of beneits (EOB) from your insurance company (recommended);

2.Itemized statement of services from your doctor or other service provider;

3.Stub from a prescripion (not the cash register receipt); or

4.Detailed receipt and prescripion for over-the-counter medicines.

Certain claims, such as insurance premiums, dental/orthodonia, and massage therapy require addiional proof. For more details read the How to File a Claim handout available online ater logging in at hraveba.org or upon request from the customer care center.

Reimburse your qualified insurance premiums automatically

You don’t have to submit a Claim Form every month for your qualiied insurance premiums. Auto premium reimbursement is available. Simply complete and submit an Auto Premium Reimbursement form. Forms are available online ater logging in at hraveba.org or upon request from the customer care center.

HELPFUL CHECkLIST:

…Atach legible proof of each expense - use an EOB whenever possible.

…Enter the correct account number.

…Sign your Claim Form.

…Keep copies of completed Claim Form and atachments for your iles.

…Do not submit more than one receipt for each expense.

…Handwriten receipts must have provider informaion stamped on them.

…If you want to note certain items on your receipts, circle the items - do not use a highlighter.

E-communication:

If you have elected e-communicaion, please note that ater logging in at hraveba.org, you (1) may withdraw your consent for electronic documents at any ime without charge by updaing your account preferences; (2) will be able to view and print copies of electronic documents (you may request paper copies at no charge by contacing the customer care center); and (3) can update your email address on ile by updaing your personal informaion. To access electronic documents, you will need a copy of Adobe Acrobat Reader sotware loaded on your computer. You can download and install a free copy at www.adobe.com. Documents provided electronically will not be mailed via U.S. Mail.

Qualified expenses and premiums:

Medical expenses you submit for reimbursement must be incurred ater you become and remain claims-eligible. Common qualiied expenses include co-pays, coinsurance, deducibles, and prescripions. Qualiied insurance premiums include medical, dental, vision, tax-qualiied long- term care (subject to IRS annual limits), Medicare Part B, Medicare Part D, and Medicare supplement plans. IRS regulaions provide that insurance premiums paid by an employer or deducted pre-tax through a Secion 125 cafeteria plan are NOT eligible for reimbursement. In addiion, premiums subsidized by the Premium Tax Credit are not eligible for reimbursement. For more details, read Qualiied Expenses and Premiums, How to File a Claim, or Facts About Premium Tax Credit Eligibility available online ater logging in at hraveba.org or upon request from the customer care center.

Legal spouse and dependent coverage:

The HRA VEBA plan covers you, your legal spouse, and qualiied dependents.

A legal spouse includes anyone you have legally married, so long as the marriage occurred in any U.S. or foreign jurisdicion that recognized the marriage, regardless of where you live now. Generally, dependents must saisfy the IRS deiniion of “qualifying child” or “qualifying relaive” as of the end of the calendar year in which expenses were incurred. Efecive September 1, 2010, your young adult children’s expenses incurred through the end of the calendar year in which they turn age 26 are eligible for reimbursement. See Deiniion of Dependent at hraveba.org for more details.

Multiple investment funds:

If your account is allocated among muliple investment funds, withdrawals (claims) will be deducted pro rata based on your balance in each fund at the ime of withdrawal unless you request otherwise in wriing.

Medicare coordination:

Secion 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) requires HRA VEBA Trust to report speciic informaion about Medicare beneiciaries covered under the Plan. The purpose of this reporing is to assist the Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees the Medicare program, coordinate the payment of beneits with other group health plans, such as your HRA VEBA. Federal rules determine whether Medicare or HRA VEBA should pay irst. Generally, your HRA VEBA account is primary to Medicare if you’re sill employed by the employer that made (or is making) contribuions to your HRA VEBA account. For more details, read Who pays irst, HRA VEBA or Medicare? available online ater logging in at hraveba.org or upon request from the customer care center.