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Claim Form Hv01 PDF Details

The Claim Form Hv01 is a form that will be used to collect information from an individual who has been involved in a vehicular accident. The purpose of this form is to gather necessary information about the individual, as well as any damages they incurred during the accident. Information such as contact details, insurance provider and policy number, driver's license number and date of issuance will be needed for processing purposes. There are also sections on the form for listing medical expenses incurred due to injuries received during the accident, which can include treatment or prescription medication costs. Compensation for lost wages may also be requested by filling out section 12 on page 2 of the claim form if applicable for your situation.

You will discover additional information in regards to the claim form hv01 by checking out the listing our team prepared for you.

Question	Answer
Form Name	Claim Form Hv01
Form Length	2 pages
Fillable?	Yes
Fillable fields	48
Avg. time to fill out	10 min 10 sec
Other names	HRA, hraveba org, VEBA, coinsurance

12

Form Preview Example

Claim Form

Skip this form! Log in at hraveba.org and submit your expenses and documentaion online.

Read instrucions and helpful informaion on reverse. Use a separate form for each covered individual.

Submit completed form to:

claims@hraveba.org | Fax: (206) 577-3020 | HRA VEBA Plan, PO Box 80587, Seatle, WA 98108

1PARTICIPANT ACCOUNT and CONTACT INFORMATION

If you have more than one claims-eligible account, enter the participant account number of the account from which you want to be reimbursed. Otherwise, your claim will be reimbursed from the account with the earliest claims-eligibility date.

ACCOUNT NUMBER or SSN	DATE OF BIRTH MM / DD / YYYY

LAST NAME

FIRST NAME			M.I.

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

	c YES
	c YES	DATE OF SEPARATION OR RETIREMENT MM / DD / YYYY
		DATE OF SEPARATION OR RETIREMENT MM / DD / YYYY
	c NO

		EMPLOYER NAME

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

AREA CODE and PHONE NUMBER	EMAIL ADDRESS (use home or personal email address)

MAILING ADDRESS			CITY		STATE ZIP

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.

2REQUIRED PARTICIPANT SIGNATURE and CERTIFICATION

I hereby certify that (1) the information provided in this claim request is true and correct; (2) the amount of this submitted claim is an accurate statement of my

(a) unreimbursed medical/dental/vision expenses after payment by insurance (if any) and/or (b) medical/dental/vision/tax-qualiied long-term care insurance premiums; and (3) the submitted claim is not reimbursable from any other source. With respect to claims submitted on behalf of qualiied dependents, I hereby certify that such person meets the Plan requirements as summarized on the reverse and is a qualiied dependent as deined under the terms of the Plan. With respect to claims for qualiied insurance premiums, I hereby certify that such premiums have not been paid by an employer, and are not eligible for pre-tax deduction through my employer’s section 125 cafeteria plan. I acknowledge and agree that any claim submitted fraudulently could result in my termination from the Plan and/or other legal action.

cPost-separation HRA Plan Participants Required Certiication: If this claim is to be reimbursed from a Post-separation HRA Plan account, check the box to certify that you were not employed (or re-employed) by the employer that made or is making contributions to your account on the date any of the following medical care expenses were incurred. Failure to provide this required certiication will cause your claim reimbursement to be delayed or denied.

X


PARTICIPANT SIGNATURE	DATE MM / DD / YYYY			PHONE NUMBER WHERE I CAN BE REACHED

3PATIENT INFORMATION (covered individual)

This claim is for:	c Myself	c Qualifying Child
(choose one)	c Legal spouse	c Qualifying Relative
	c Other: ___________________________________

LAST NAME

THIS INFORMATION IS REQUIRED BY FEDERAL LAW:

Is this person currently, or have they ever	c YES
been, enrolled in Medicare Part A or Part B?	c NO

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

FIRST NAME

M.I.

c Male

MEDICARE ID NUMBER (HICN)

PART A

PART B

c Female

EFFECTIVE DATE

EFFECTIVE DATE

DATE OF BIRTH MM / DD / YYYY

SOCIAL SECURITY NUMBER

4REIMBURSEMENT REQUEST FOR QUALIFIED OUT-OF-POCKET EXPENSES

REMINDER: You must include proof of each expense (e.g. Explanation of Beneits (EOB), detailed receipts, etc.). Claims for employee-paid premiums deducted after tax require a letter from the employer conirming that no pre-tax option exists.

DATE OF SERVICE

SERVICE PROVIDER OR ITEM PURCHASED FROM

TYPE OF SERVICE or ITEM (Ofice visit, Rx, Dental, etc.)

AMOUNT YOU PAID

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

$

$

$

$

$

QUESTIONS? 1-888-659-8828 | customercare@hraveba.org | hraveba.org

Important informaion and helpful ips on reverse u

HV01 (02-15 PRC)

Claim Form

Page 2 of 2

Want to know more? First ime submiing a claim?

Get your money back fast

Following the ips and instrucions below will help you submit “clean” claims for faster processing. For more detailed guidelines, read How to File a Claim available online ater logging in at hraveba.org. Standard processing ime is ive business days from the date received. If you’re not signed up for direct deposit, remember to allow addiional ime to receive your paper checks in the mail. Email (recommended), fax, or mail your completed Claim Form and proof of expense(s) to the Plan as indicated at the top of the Claim Form.

Enter your participant account number

If you have more than one claims-eligible paricipant account, include the paricipant account number of the account from which you want to be reimbursed. Otherwise, your claim will be reimbursed from the account with the earliest claims-eligibility date.

Fully complete each section of the Claim Form

Missing informaion, paricularly in secion 3, will likely result in denied claims. Federal law requires the Plan to have on ile the full name, Social Security number, gender, and date of birth of all covered individuals.

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.

Important Informaion

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.

QUESTIONS? 1-888-659-8828 | customercare@hraveba.org | hraveba.org

How to Edit Claim Form Hv01 Online for Free

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customercarehraveba empty spaces to complete

Include the required information in the c Post, separation HRA Plan, PARTICIPANT SIGNATURE, PATIENT INFORMATION (covered, LAST NAME, FIRST NAME c Male c Female, DATE OF BIRTH MM / DD / YYYY, DATE MM / DD / YYYY, PHONE NUMBER WHERE I CAN BE REACHED, This informaTion is required by, Is this person currently, NAME EXACTLY AS IT APPEARS ON, MEDICARE ID NUMBER HI, CN PART A EFFECTIVE DATE, PART B EFFECTIVE DATE, and REIMBURSEMENT REQUEST FOR field.

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