HRA Claim Forms

BASIC is pleased to announce a new process for the submission of claims and verifications.

We have created a secure claim upload portal for claim/verification submission. This new process allows you to complete a reimbursement request or verification form, attach documentation and receive confirmation that your submission was successfully uploaded. Please  submit your reimbursement/verification request here.

Below you will find a variety of claim forms due to the different plans we have available. Please read the description of each to find the appropriate claim form for your plan. If you have a question on which form you should use please call one of our customer service representatives at (888) 472-0777.

BASIC HRA Reimbursement Form

Employees who do NOT have a BASIC HRA Debit Card use this form to request reimbursement from their BASIC Flex account.
Non Debit Card Users (pdf)

BASIC HRA Benefits Card Reimbursement/Verification Form

Employees 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 Users (pdf)

BASIC Flex 1Direct Reimbursement Form

Flex 1Direct Users (pdf)

BASIC Flex/BASIC HRA Reimbursement Form

Employees that have both a BASIC Flex and BASIC HRA plan use this form to request reimbursements.
Flex /HRA Users (pdf)