Search results
To request reimbursement for your health care premiums use this form. ①Account Holder Information: The Account Holder is usually the retiree or the surviving spouse. ②Reimbursement Information: Complete this section to indicate the Date of Service; Type of Coverage (e.g. Medigap;) Covered Participant Name and Relationship to the account ...
instructions for managing your reimbursement account and explains how to be reimbursed for your eligible expenses. Via Benefits reimbursement accounts are administered by Extend Health, LLC. You will submit your reimbursement requests to Via Benefits and be reimbursed from your available funds. Download the Via Benefits Accounts mobile app to ...
Log in to your account at www.viabenefitsaccounts.com. Submit your claim online and attach the image or scanned copy of your receipt(s) online. Option 1 & 2 are the fastest and most convenient way to complete your claims and send us your documents.
3 sie 2022 · You need to submit reimbursement requests to receive funds from your reimbursement account for your eligible expenses. (You will not receive a debit card.) Use the Via Benefits Accounts mobile app, the website, or a Reimbursement Request Form to submit reimbursement requests.
This form is used to submit reimbursement requests for the Life Planning Account. Parts I–IV are to be completed by an eligible retiree (retired on or before December 31, 2003) or the surviving spouse of an eligible retiree.
INSTRUCTIONS. Fill in the information requested below for the medical expenses you or your eligible dependents have incurred. For each item, you must include a copy of a receipt showing the date of service or a copy of an explanation of benefits (EOB) from your insurance carrier.
To request reimbursement for your health care expenses use this form. ①. Account Holder Information: The Account Holder is usually the retiree or the surviving spouse. ②. Reimbursement Information: Complete this section to indicate the Date of Service; Type of Coverage (e.g., Medical); Covered Participant Name and Relationship to the ...
