|
HRA Code 105 Forms
A variety of HRA IRS Code 105 Forms and information is available in both a .pdf and .doc (msn word) format. The forms can be printed, completed and then faxed, mailed or emailed to claims@wbp125.net.
If you are unable to open the forms click here to download a free PDF and/or WORD reader.
_____________________________________________________
|
FFF: .pdf (Adobe) / .doc (MSN Word)
HIPPA guidelines require that the privacy policy of a covered entity be disclosed to plan participants. This notice provides Worksite Benefit Plans, Inc.'s privacy policy and should be provided to all plan participants.
HRA Claim Form: .pdf (Adobe) / .doc (MSN Word)
Used when requesting reimbursements from your Health Reimbursement Arrangement Plan.
Allowable Over The Counter Items: .pdf (Adobe) / .doc (MSN Word)
This form provides a list of generally acceptable over the counter (OTC) items available for reimbursement. While these items are qualified you should consult with your Company's HRA Code 105 plan to ensure they are allowable.
Direct Deposit Authorization: .pdf (Adobe) / .doc (MSN Word)
This form authorizes Worksite Benefit Plans, Inc. to create an ACH transfer (Direct Deposit) of your reimbursements into your personal checking or savings account. Most transfers take two to five business days. Note: Not all employers allow for Direct Deposit. If in doubt you should consult with your employer to see if Direct Deposit is available to you.
Privacy Statement: .pdf (Adobe) / .doc (MSN Word)
HIPPA guidelines require that the privacy policy of a covered entity be disclosed to plan participants. This notice provides Worksite Benefit Plans, Inc.'s privacy policy and should be provided to all plan participants.
|
_____________________________________________________________
|
|