Fillable STEP 1 HRA/FSA Consolidated Claim Form (MidAmerica)

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STEP 1 HRA/FSA Consolidated Claim Form (MidAmerica)

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The STEP 1 HRA/FSA Consolidated Claim Form (MidAmerica) form is 2 pages long and contains:

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  • 13 check-boxes
  • 128 other fields

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HRA/FSA Consolidated Claim Form
Return this completed form to:
Mail: MidAmerica Administrave & Rerement Soluons
An: PO Box 24927, Lakeland, FL 33802
Fax: (863) 577-4460 | Phone: (855) 329-0095
F2009-001 (0721) | MidAmerica HRA/FSA Claim Form | Fax: (863) 577-4460
STEP 2
Opon 1
Opon 2
Claim Informaon
One-Time Expenses
Recurring HRA Premium Expenses (Payable to Self Only)
Approved claims are processed within 7–10 business days. Be sure to aach acceptable documentaon as outlined in the instrucons. Failure to provide the requested
informaon or acceptable documentaon may delay your request. Applicable distribuon fees will be deducted from the total eligible claim amount (per IRS guidelines). For
PSERS Rerees: If you are receiving PSERS monthly premium assistance, you must reduce your medical premium reimbursement request by this amount.
PLEASE INITIAL ALL BELOW: (Note: Inials are required for processing. Please review claim instrucons for addional informaon.)
I understand that I cannot simultaneously parcipate in a Health Reimbursement Arrangement (HRA) and receive an advance Premium Tax Credit (PTC). Any receipt
of a PTC while receiving reimbursements from my HRA can result in adverse tax consequenses, per IRS regulaons.
I understand my recurring premium expense(s) remain in eect and reimbursable through the policy expiraon date. I understand I am required to renew my
recurring claim in advance of the policy expiraon by subming a new claim form and updated policy documentaon for approval.
I understand if at any me prior to the policy expiraon date my premium amount changes, I begin to receive an advance Premium Tax Credit (PTC), or the policy
terminates, I must nofy MidAmerica to avoid potenally adverse tax consequences per IRS regulaons.
Complete the following table for any one-me eligible expenses incurred by the parcipant, spouse, or eligible dependent. Expenses may include (one-me) premiums,
long-term care, prescripons, medical, dental, or vision. For a complete list of eligible expenses, please visit IRS Publicaon 502: Medical and Dental Expenses.
Complete the following table for any recurring HRA premium expenses incurred by the parcipant, spouse or eligible dependent. Expenses submied here will be
established as recurring automac disbursements processed approximately 30 days prior to the payment due date. For example, you will receive payment for January’s
premium in early December.
NOTE: Choose one or both opons.
NOTE: Choose one. HRA Only FSA Only FSA then HRA*
STEP 1
Parcipant Informaon
Employer
First Name Last Name
Email Address
Check if permanent address change:
Acvely employed with employer? If no, separaon date?
Mailing Address
City State Zip Telephone
M.I.
Date of Birth (mm/dd/yyyy)
Social Security Number
Date of
Expense
Name of Service Provider
Name of Covered Parcipant, Spouse,
or Eligible Dependent
Service Provided
Payable to:
(Self, Provider)
Amount to
Reimburse
*FSA funds used unl exhausted, followed by HRA funds. Total One-Time Claim Expenses:
Policy
Eecve
Date
Name of Insurance Provider
Name of Covered Parcipant, Spouse, or
Eligible Dependent
Type of
Insurance
Premium
Group
Insurance?
(Yes/No)
Policy
Expiraon
Date
Amount to
Reimburse
Total Recurring Premium Expenses:
STEP 3
STEP 4
STEP 5
Opon 1
Opon 2
Payment Opons
Addional Informaon
Authorizaon
Self
Insurance or Service Provider
Please note one-me expenses from Step 2, Opon 1 may be payable to self or your insurance or service provider. Recurring premiums are only payable to self.
FSA Daycare/Dependent Care Provider and Dependent Informaon:
Complete if any of the above expenses were day care or dependent care expenses.
Death Claim:
Upon the death of a parcipant, the parcipant’s surviving spouse and/or eligible dependents may submit a death claim for reimbursement of eligible expenses for
themselves or nal medical expenses incurred by the parcipant unl the vested account balance is exhausted. Distribuons on behalf of a deceased parcipant require a
photocopy of the death cercate. Please reference Plan Highlights for more informaon regarding beneciaries. Please provide payment name and the address below.
Cancellaon of Recurring Premium:
Indicate which previously submied recurring premium you would like to cancel below, the reason for cancellaon, and eecve date of the cancellaon.
PROVIDER INFORMATION Note: Required in addion to copies of
bills and/or receipts.
If you selected New Direct Deposit, please provide your banking informaon below. Your HRA/FSA distribuons may be deposited directly into your account or joint
account with your spouse at your bank or other nancial instuon.
How would you like to receive your reimbursement? Choose one:
NEW DIRECT DEPOSIT INSTRUCTIONS:
NOTE: Choose opons that apply from Step 2.
NOTE: Choose any that apply.
Check in the mail New Direct Deposit Direct Deposit (already on le with MidAmerica)
Bank Name
Payee Name
Name on Account
Account Number
Policy # / ID # / Account ID #
Account Type (e.g., Checking, Savings)
Address
Dependent Name
Name on Account
Premium Type Premium TypeEecve Date Eecve DateReason for Cancellaon Reason for Cancellaon
Provider Signature
Dependent Name
Provider Tax ID
City
Age
Address
Age
Signature Date (mm/dd/yyyy)
State Zip
I request payment from the reimbursement account for the expenses listed above in Step 2. To the best of my knowledge, my statements on this form are true and complete. I cerfy
that all expenses for which reimbursement or payment is claimed were incurred either by me, my spouse or my eligible dependent(s). I understand that a medical expense is considered
incurred when medical care is provided to me or my eligible dependent(s), not when I am formally billed, charged or have paid for the medical care. Therefore, I understand that insurance
premiums must be incurred prior to reimbursement, and I cannot be reimbursed for an enre year of premiums in advance. I cerfy that the medical expenses in this claim are eligible for
reimbursement and are “qualifying expenses” as dened by the Internal Revenue Code Secon 213(d). I understand that, if these medical expenses are not qualied medical expenses, I
may be liable for the payment of all related taxes on amounts received pursuant to this claim. I cerfy that the medical expenses claimed are not covered by insurance and have not been
reimbursed or cannot be reimbursed under any other health plan coverage. I cerfy that I have not previously submied this claim for reimbursement and that this is not a duplicate claim. I
take full responsibility for the accuracy of all informaon I have provided. I further understand that reimbursed expenses cannot be claimed as a credit on my personal income tax return.
If I provided direct deposit informaon in Step 3 of this claim form, I authorize MidAmerica Administrave & Rerement Soluons to deposit my HRA and/or FSA claims directly into my
account unl I give further wrien noce to MidAmerica. I understand that it may take up to 72 business hours from the me MidAmerica processes my payment for the funds to post to my
designated bank account. Also, I grant MidAmerica the right to correct any electronic funds transfer resulng from an erroneous overpayment by debing my account to the extent of such
overpayment.
As part of the Aordable Care Act, the DOL has mandated employees be permied to either irrevocably suspend their HRA for a xed period of me or permanently opt-out of the HRA by
forfeing their account balance and waiving any future contribuons. Elecng either opon would preserve the eligibility of an individual to claim a Code § 36B premium tax credit, otherwise
known as a Premium Subsidy for Healthcare Exchange coverage. Should you choose to suspend your HRA, you, your spouse and any qualifying dependents will cease to have access to the
HRA during the suspension and will be ineligible to incur any new expenses for reimbursement during the suspension. For your account to be reacvated, MidAmerica must receive a wrien
noce requesng the account be unsuspended. Please be advised that the account becomes available at the start of the plan year following the request to unsuspend.
Parcipant Signature
F2009-001 (0721) | MidAmerica HRA/FSA Claim Form | Fax: (863) 577-4460
ABA Roung Number
Signature Date (mm/dd/yyyy)
Aach an addional sheet to supply informaon for mulple insurance or service providers.
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STEP 1 HRAFSA Consolidated Claim Form (MidAmerica)

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Completed 28 July 2021

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