Submit an HRA

To submit a HRA, please fill out the form below.

All cells are required. The Purple Card will reach out for any additional needed details. If all information is accurate and complete, your HRA will process within 10-15 business days.

About You

Employee Name(Required)
Employer Name(Required)
MM slash DD slash YYYY
Your Email Address(Required)
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Plan Type(Required)
Plan Tier(Required)
Drop files here or
Accepted file types: pdf, jpg, png, Max. file size: 100 MB, Max. files: 5.
    Upload an Explanation of Benefits from your Insurance with the highest family or individual deductible met.

    The Purple Card Hotline
    Local: (972) 788-9118

    Hours of Operation:
    Monday – Friday
    8:30am – 5:30pm CST