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/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)