Employee Claim Forms

Did you know that instead of using the paper claim forms employees can submit claims online or through OCA’s mobile app?

HRA Claim Form

For Medical Expenses, you must provide a copy of the insurance carrier’s Explanation of Benefits (EOB) as supporting documentation for your claim form. If this is not provided, the claim cannot be processed. Should there be any discrepancy between the information on the EOB and the information provided on the claim form for that expense, the EOB will rule.

 

Commuter Claim Form

Due to recent IRS changes, employees can only be reimbursed for transit expenses through OCA’s terminal restricted debit card (mySource Card). If enrolled in parking, employees may be reimbursed via paper check or direct deposit.

FSA Claim Form

Please include a provider receipt or insurance carrier (EOB) that contains date of service, bill amount amount, service description. Cancelled checks, non-detailed credit card receipts, or generic cash receipts do not provide all the information necessary to substantiate claims and cannot be accepted.

 

Dependent Care Claim Form

Please include a receipt that contains the Care Provider Name, Service Date Range, and billed amount. Expenses submitted for Dependent Care Reimbursement must allow the participant to be gainfully employed (or looking for work).