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 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.

HRA Authorization for Release of PHI

The HRA 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.

HRA Direct Deposit Form

The HRA 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.

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.

HRA Partial 213d Eligible / Ineligible List

The HRA Partial 213d Eligible / Ineligible List  provides common examples of eligible and ineligible HRA expenses.

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