Use this form for inpatient/outpatient hospital copay reimbursement from the Garnet Valley Pool Account; specify "HRA" on plan type (Do NOT use your FSA Debit Card for Inpatient/Outpatient Reimbursement).
GVSD staff with Blue Cross medical benefits coverage, use this form to obtain reimbursement if you received a flu shot or FluMist in a location other than a doctor’s office. Please submit one form for each member.
