Getting and Submitting a Reimbursement Request Form
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.
The preferred method for submitting reimbursement requests is through the website or Via Benefits Accounts mobile app. Requests submitted through the website or mobile app are typically processed within five business days. For more information, read Submitting a Reimbursement Request.
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 delivery by mail.
Photocopying the Form
If you’ve contacted Via Benefits for a Reimbursement Request Form within the past year, you may photocopy the form for future use. Do not photocopy or submit a form that is personalized for another individual.
Submitting the Form
Once you have received and completed the form, return it to the address printed on the back.
*Via Benefits reimbursement accounts are administered by Extend Health, LLC.