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Health Care Reimbursement Account Claim Form

Please use this form to request reimbursement for: eligible expenses not covered by any insurance plan, or the unpaid balance of a health, dental, or vision care claim submitted under an employees group plan.

Questions about a claim? Please contact HealthEquity at 877-924-3967.

Form NameFormat
Health Care Reimbursement Account Claim Form
(can be filled in electronically)
PDF

Categories

Benefits - Health Care Reimbursement Account, Benefits - Reimbursement Accounts