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.

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 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:

* 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.