LINECO HRA Account
821 Parkview Blvd.
Lombard, IL 60148
www.linecohra.org
HEALTH REIMBURSEMENT ACCOUNT REIMBURSEMENT REQUEST FORM
1.
Type or print information (items 1 through 8) on the Employee Section below. Only one patient can be listed on a
request form. However, more than one provider can be listed for that one patient.
2.
Enter the total amount for which the claim is being made in the appropriate sections. A minimum of $25 should
be accumulated before you submit a claim.
3.
Supporting documentation must accompany this request form. Supporting documentation includes the following:
Explanation of Benefit Statement(s) indicating deductibles, co-insurance, co-payment or amounts in excess of
usual and customary charges from any medical/dental plan(s) under which you and/or any of your eligible
dependents are covered, or if the expense is not covered under your medical/dental plan, itemized bills from
doctors, dentists or other suppliers for insured expenses.
4.
Retain copies of supporting documentation for your records.
5.
Send completed claim form and supporting documentation, in a personal and confidential envelope, to the Fund
Office at the address above.
NOTE: ANY ITEMS FOR WHICH YOU ARE REIMBURSED CANNOT BE CLAIMED AS DEDUCTIONS
OR CREDITS ON YOUR FEDERAL INCOME TAX RETURNS.
UNREIMBURSED HEALTH CARE EXPENSES
Date of Service _______________________
Claim Amount to be Reimbursed
Deductible ________________________ $______________________
Coinsurance / Co-payments ___ $
Not covered by plan $
Total $
I certify that either I and/or my eligible dependents have incurred the expenses for which reimbursement is claimed
from the Health Care Reimbursement Account, and I further declare that I have not and will not de- duct these
expenses on my individual income tax returns. No assignment will be accepted:
Employee Signature Date
