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Health Reimbursement Arrangement Claim Form

This form is for GEHA High Deductible Health Plan (HDHP) members who have health reimbursement arrangements (HRAs). Use this form to get reimbursement from your HRA for qualified out-of-pocket medical expenses that are not submitted to GEHA by your doctor, hospital, dentist or pharmacy. Qualified expenses submitted by your provider are automatically reimbursed from your HRA up to the amount of your deductible.

This form is for use only by HDHP members with HRAs. No claim form is required for HSAs.