WebWelcome to your Davevic Benefit Consultants Consumer Portal. This one-stop portal gives you 24/7 access to view information and manage your Flexible Spending Account (FSA) … WebPlease note: You must submit a copy of your Explanation of Benefits form to be reimbursed. Name of Service Provider (doctor, hospital) Deductible/Co-Insurance Medical Expense …
Health Reimbursement (HRA) Claim Form - Innovative …
WebP O Box 160, Pewaukee, WI 53072-0160, 262-549-9190 or toll free 800-242-7018, Fax 262.549.3549, [email protected] Health Reimbursement (HRA) Claim Form Print Participant's Last Name First Name OEF Number or SSN Participant Information (IUOE 139 member) Participant Authorization (this form must be signed or it will be returned) WebCOBRA Administration Commuter Benefits Direct Billing / Retiree Billing Flexible Spending Accounts (FSA) Health Reimbursement Arrangements (HRA) Health Savings Accounts (HSA) and Limited Purpose FSA (LPFSA) Mobile Application Download our mobile application in the Apple App Store or the Google Play Store. hayward ca city government
HRA Claim Form - amben.com
Weboriginal claim form and supporting documents for your records. Where To Send A Claim Mailing Address: Davevic Benefit Consultants, Inc. 902 South Center Street P. O. Box 976 Grove City, PA 16127 Fax: 724-458-4464 E-mail Attachment: [email protected] Phone: 724-458-7255 or toll free 800-854-4099 Online Account Access: www.davevic.com WebPart 3: Attach your receipts or Explanation of Benefit forms Part 4: Certify and sign Mail or fax pages 2 and 3 of this form along with your receipts Mail to: Health Care Account Service Center P.O. Box 740378 Atlanta, GA 30374 uFax: (248) 733-6148 u Toll-free fax: 1-866-262-6354 Please reimburse me for the expenses I am submitting on this form. WebEmployees with a BASIC HRA Debit Card use this form to request reimbursement from their BASIC HRA account or to submit verification for card transactions. HRA Debit Card … hayward ca city council