Claim filing requirements - HealthEquity

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HSA Reimbursement form Mail or fax completed forms to:Address: HealthEquity , A n: Member Services15 W Scenic Pointe Dr, Ste 100, Draper, UT 84020 Fax: Account Holder Informa onLast NameFirst Street Address CityStateZIPE-Mail Address (required)Day me Phone( )SSN or HealthEquity ID Number (6 or 7 digits)Reimbursement Informa onProvider NameDate of expensePa ent NameTotal Reimbursement*Type of expense: medical Prescrip on Dental Vision (Note: No documenta on is needed. Keep receipts for your records.)*If the requested reimbursement amount is higher than your available balance, we will only process the reimbursement up to the available balance in the account. An account closure fee is held in reserve from your account and may not be used for Method Op on 1 Check This method is slower.

A Letter of Medical Necessity (LMN) will still be required for vitamins and dual-purpose OTC items. The LMN is good for a 12 month period and must be dated on or before services rendered. The LMN form is available under Forms and Docs in the Member Portal. Note: OTCs purchased in 2019 will still

  Form, Medical, Letter, Healthequity, Necessity, Letter of medical necessity