HOW TO FILE A CLAIM FOR RETENTION BENEFITS REIMBURSEMENT To assure proper identification and prompt payment, Part A should be completed, and the participant should sign the release of information block. You may submit a fully itemized receipt on the provider's letterhead, or the provider can check the boxes in Part B for the services/ supplies being provided, furnish all the receipts required, sign, and date the Part B claim form. The Form and necessary receipts are to be sub

Excepted Benefit Health Reimbursement Account (HRA) Claim Form Mail, fax or email completed form and documentation to: 27 Roland Avenue, Suite 100, Mt. Laurel, NJ 08054 Fax: 856-793-3100 Email: aramirez@tsonline.com Please print clearly. All information in each section must be completed. Attach required documents. Refer to eligible expenses on the reverse side of this form. The participant must sign each Claim Form that is submitted. Reimbursement will not be processed witho

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