MidAmerica Claim Form

The MidAmerica Claim Form allows you to submit one-time eligible expenses or recurring premium expenses for reimbursement from your HRA/FSA account. Also encompasses reimbursement for Dependent Care expenses, Death Claim requests, and cancellation of existing recurring premiums. 

Claim Instructions

Important process and compliance information required for successful claim submission.

HRA FSA Statement of Medical Necessity Form

The HRA / FSA Statement of Medical Necessity Form is signed by your doctor and shows that the service you received is medically necessary. Common services that require this form include: counseling, physical / occupation / massage therapy, and acne treatment.

FSA (125) Plan Enrollment Form

The FSA 125 Plan Enrollment Form allows you to enroll in your employer’s FSA program during their open enrollment period.

HRA/FSA Restriction/Suspension Form

The HRA / FSA Restriction / Suspension Form allows you to restrict your FSA / HRA (or suspend, if appropriate) if you, your spouse, and / or eligible dependents are contributing to a Health Savings Account (HSA), or if you want to qualify for a subsidy on the exchange.

Change in Status Election Form

The Change in Status Election Form allows you to update your election amount if you have had a qualifying event during the plan year. Common examples of qualifying events include divorce, birth of child or adoption, change in dependent status, etc.

COBRA Election Form

FSA Authorization for Release of PHI

The FSA Authorization for Release of PHI allows you to authorize certain individuals to receive information on your claims, payment, and other related health information about you. The form also includes an option that prohibits any type of disclosure to anyone other than yourself.

FSA Direct Deposit Form

The FSA Direct Deposit Form allows you to request that your reimbursements be directly deposited into your bank account. You may also use this form to change your current direct deposit information, or cancel your direct deposit.

HCRA Mid-Year Election Changes

The HCRA Mid-Year Election Changes sheet outlines what life events could qualify you for a mid-year election change.

Questions on HRA / FSA reimbursement documentation requirements? Check out our Documentation FAQs.