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HRA CLAIM FORM Employer: Health Reimbursement Arrangement (HRA) Employee Name: S.S.# - - Address: City: State: Zip: Email Address: check if new address Day Phone: ( ) CLAIM DETAIL Date of Service: Who received service: Type of Service: Amount: $ $ $ $ ►Please review the Summary Plan Description (SPD) for what is covered by your Plan. ► Minimum Claim: $25 I understand that if I claim these expenses here, that I may not claim the same expenses elsewhere, or as tax credit or tax deduction. I understand the minimum claim check mailed is $25. I certify that to the best of my knowledge these statements are complete and true. I authorize the release of any medical information to my spouse and to Ben-X, LLC using the above email address for communication regarding my claim informaton. Participant Signature Date Completed forms and all required receipts may be Faxed, E-mailed or Mailed to Ben-X,LLC Ben-X, LLC Fax: Send via Fax for Faster Claim Processing! (801) 852-8797 (use this form as the cover page) Email: [EMAIL REDACTED] Mail to: Claims at Ben-X, LLC · 3300 N Running Creek Way ·Suite A3 · Lehi · UT· 84043 Questions? Email: [EMAIL REDACTED] ©Ben-X, LLC 2019 Rev 4 – 12/18 Sign Here PRINT SAVE AS CLEAR FORM