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Health Care Claim Forms

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SAVINGS & REIMBURSEMENT ACCOUNT CLAIM FORMS

If you have a Flexible Spending Account (FSA) or Health Reimbursement Account (HRA), you can submit your claim and eligible expenses. To determine if the FSA expenses you wish to submit are eligible, check the list below. Please see your benefit plan documents to find out which health care expenses are eligible under your HRA. Employers may choose to limit which expenses they allow under their HRA plans.

Use this form when you pay for a covered expense out-of-pocket and you want to request reimbursement from your MRA, HCSA, or DCSA. If you are covered under the JPMorgan Chase Medical Plan and you have elected automatic claim payment, your MRA is the first source of payment for medical and prescription drug expenses. If your MRA has been exhausted, the plan will look at your HCSA and use any available funds in that account. Your HCSA also pays for dental and vision expenses.

To determine if the expenses you wish to submit are eligible, follow the steps below. If you have elected a debit card, you will determine the order in which expenses are paid.

Step 1:    Review Eligible Expenses: 2018 Expenses 2018 FSA Expenses 2017 Expenses 2017 FSA Expenses
Step 1:    Review Eligible Expenses: 2018 Expenses 2018 FSA Expenses 2017 Expenses 2017 FSA Expenses
Step 2: Review Do's and Don'ts
Step 3:    Submit MRA/HCSA/DCSA Form
Step 3:    Submit FSA/HRA Form

Note: If you have both an FSA and an HRA, you do not need to choose which one will pay your claim first. Your employer will set which financial account for your plan automatically pays your claim first. The first-pay account is usually the HRA.

If you prefer to submit your eligible expenses in the mail, you can use the hardcopy claim form provided below.

If you have a Flexible Spending Account (FSA) or Health Reimbursement Account (HRA), you can submit your claim and eligible expenses.To determine if the FSA expenses you wish to submit are eligible, check the list below. Please see your benefit plan documents to find out which health care expenses are eligible under your HRA. Employers may choose to limit which expenses they allow under their HRA plans.

Use this form when you pay for a covered expense out-of-pocket and you want to request reimbursement from your MRA, HCSA, or DCSA. If you are covered under the JPMorgan Chase Medical Plan and you have elected automatic claim payment, your MRA is the first source of payment for medical and prescription drug expenses. If your MRA has been exhausted, the plan will look at your HCSA and use any available funds in that account. Your HCSA also pays for dental and vision expenses.

To determine if the expenses you wish to submit are eligible, follow the steps below. If you have elected a debit card, you will determine the order in which expenses are paid.

Step 1: Review Do's and Don'ts
Step 2:    Submit FSA/HRA Form
Step 2:    Submit MRA/HCSA/DCSA Form

Note: If you have both an FSA and an HRA, you do not need to choose which one will pay your claim first. Your employer will set which financial account for your plan automatically pays your claim first. The first-pay account is usually the HRA.

If you prefer to submit your eligible expenses in the mail, you can use the hardcopy claim form provided below.

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