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  • ICHRA Attestation Form

    ICHRA Attestation Form

  • INDIVIDUAL COVERAGE HRA ATTESTATION

    ONGOING COVERAGE SUBSTANTIATION

    This form is required to be completed at least MONTHLY

  • As a participant in an Individual Coverage Health Reimbursement Account  (“ICHRA”), you must certify that you were covered by an individual health insurance policy, Medicare Part A and B, or Medicare Part C on the date that you or an eligible dependent incurred a medical service or expense for which you are requesting reimbursement through the ICHRA.

    This is required to remain in compliance with IRS rules and regulations.

  • EMPLOYEE ATTESTATION

  • I,   *   *, attest that the information below is correct to the best of my knowledge and that I have obtained and am currently enrolled in an individual health insurance policy with the insurer identified below for the month of   *      .   

  • I have obtained and am currently enrolled in an individual health insurance policy with the insurer identified below for the month stated;*
  • I will not terminate, cancel or discontinue my individual health insurance policy during the month stated above, and I will not use the Mobile Summit App for payment at any time when such policy has been terminated, cancelled, or discontinued;*
  • It is my responsibility to notify NeuBridg or Midwest Group Benefits (Third Party Administrator (“TPA”)) when my health insurance coverage terminates, is no longer active, lapses, or is not renewed;*
  • If I use the Mobile Summit App for payment at any time following termination, cancellation, or discontinuance of my individual health insurance policy, I will promptly (but in no event less than thirty (30) days following payment) return to the ICHRA all amounts paid by the ICHRA to me or on my behalf; and*
  • The ICHRA shall retain all rights and remedies to collect amounts paid to me or on my behalf following termination, cancellation, or discontinuance of my individual health insurance policy.*
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  • Unfortunately, your request is being denied.

     

    The denial is due to your answer of "Disagree" in one or more of the questions.

    Please submit a new request when you can agree to all of the questions. You may also click on the Back Button to review your answer(s) in case you misunderstood the question.

    If you have further questions, please do not hesitate to contact NeuBridg.

    Thank you,

     

    NeuBridg, Inc. 

  • Family Medical Expense Reimbursement

    (If Applicable)
  • Do you have a family member for whom you are requesting reimbursement of medical care expenses?*

  • Family Member Reimbursement of Medical Care Expenses

    Complete the following if you have a family member for whom you may request reimbursement of medical care expenses:

  • My family members will not cancel or discontinue their individual health insurance policy during the month as stated above, and neither my family members nor I will use the Mobile Summit App for payment at any time when such policy has been terminated, cancelled, or discontinued;*
  • It is my responsibility to notify NeuBridg or Midwest Group Benefits (Third Party Administrator (“TPA”)) when any of my family members’ health insurance coverage terminates, is no longer active, lapses, or is not renewed; and*
  • If my family member or I use the Mobile Summit App for payment of expenses incurred by one of my family members at any time following termination, cancellation, or discontinuance of my family member’s individual health insurance policy, I will promptly (but in no event less than thirty (30) days following payment) return all amounts paid to ICHRA; and*
  • The ICHRA shall retain all rights and remedies to collect amounts paid to a family member or on a family member’s behalf following termination, cancellation, or discontinuance of my family member’s individual health insurance policy.*

  • INSURANCE POLICY INFORMATION

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  • * If applicable

  • By electronically signing this document, I hereby affirm that the above information is true and correct. I further hold NeuBridg, Inc. and their respective agents and assigns as well as Midwest Group Benefits, Inc. harmless against all costs, liabilities, and expenses of every kind that would result due to inaccurate information provided by me. Any action to enforce these indemnification rights shall be brought exclusively in the state or federal courts located in and for Des Moines, Iowa.

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