Follow the steps to complete your claim form online.

1. Click ‘Get Form’ button to access the Pay Me Back Claim Form and open it for editing.
2. Complete the account holder information section. Fill in your last name, first name, social security number, employer or program sponsor's name, zip code, and birth month and day in MM/DD format. Include your email address only if it is new.
3. Read the certification and authorization statement carefully. You must certify that all claimed services were provided while you were covered under the Plan and that expenses have not been reimbursed elsewhere. Sign and date the form in the designated areas.
4. In the unreimbursed medical expense claims section, list the date the expense was incurred, the name of the service provider, describe the expense, and indicate for whom the expense was incurred.
5. Attach appropriate receipts showing the date and type of service. Ensure that canceled checks or balance statements are not included. Number each attachment page for clarity.
6. Submit your claim. For faster processing, you can fax your completed form along with receipts to the toll-free fax number provided or email a scanned PDF of the claim with receipts, ensuring the claim form is the first page of the scan. If you do not use fax or email, mail your claim to the specified address.
7. Remember to keep the original claim form and any supporting documents for your records. You can verify that your claim has been received through the available online services.

Ensure your claims are processed quickly by completing your Takecarewageworks claims online today.