Getting and Submitting Reimbursement Request Forms
This article applies to you if you have a Via Benefits reimbursement account, sometimes called a Health Reimbursement Arrangement.*
If you receive an Individual Coverage Health Reimbursement Arrangement (ICHRA) through your employer, you can’t submit reimbursement requests using a paper form. Please see the ICHRA Reimbursement QuickStart Guide for more information.
The preferred method for submitting reimbursement requests is through the Via Benefits website or the mobile app. Requests submitted through the website or mobile app are typically processed within five business days. For more information, read Submitting Reimbursement Requests.
You can also submit a reimbursement request by completing and returning a Reimbursement Request Form. However, submitting a paper form is less secure and may take up to 10 additional days to process compared to requests submitted through the website or mobile app.
Getting the Form
The Reimbursement Request Form isn't available online. To request one, call us at 1‑866‑322‑2824 (TTY: 711) and follow the prompts in our automated voice system or speak directly with a Via Benefits representative. Please allow two to three business days for processing, plus additional time for mail delivery.
Photocopying the Form
If you’ve contacted Via Benefits for a Reimbursement Request Form within the past year, you may use photocopies of the form for future reimbursement requests. Remember to copy both sides of the form. Do not photocopy or submit a form that is personalized for someone else.
Submitting the Form
Once you complete the form, return it to the address printed on the back of the form. Mailing addresses vary by individual, so we cannot provide a return address in this article.
*Via Benefits reimbursement accounts are administered by Extend Health, LLC.