Submit FSA & HRA Claims Forms Online

Enter the following information in the spaces below for each expense item. Attach all necessary receipts to the bottom of the form. In order to submit electronic reimbursements online, you must attach scanned receipts.

Hemwatie Sankar-Polwah

10/18/1984

*****l Security Number

4803 E POINSETTIA AVE.
TAMPA FL 33617

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Please enter a valid Day Time Phone Number.
Please enter Employer Name.

Enter Expense

Please enter Patient First Name.
Please enter Patient Last Name.
Please select a valid
Please enter the Provider Name.
Please enter Requested Amount
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Provider Address
Please enter the Street 1.
Please enter the City.
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Please enter the Zip Code.
Please enter the brief 'Description of Service'
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Receipt Upload

Maximum combined File Size (3 MB). Formats accepted: .jpg, .jpeg, .png, .pdf Scanned Documents - Recommended Resolution: 300 dpi

CERTIFICATION FOR REIMBURSEMENT

By adding my name in the boxes below and pressing Submit Claim, I certify that any expenses for which I am requesting reimbursement for my Health Care financial accounts, as itemized above, were incurred by me (and/or my spouse and/or eligible dependents) for medical care as permitted under the Health Care financial accounts, and have not been reimbursed and I will not seek reimbursement under any other plan. I understand that expenses reimbursed through the Health Care financial accounts programs cannot be used to claim any federal income tax deduction or credit. To the best of my knowledge and belief, my statements are complete and true.

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You must use a 'First name' to submit a claim.
You must use a 'Last name' to submit a claim.
10/10/2018

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