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Employee s Signat ure Date UNREIMBURSED MEDICAL EXPENSE CLAIMS Date Expense incurred mm/dd/yy Name of Service Provider Expense Description Attach appropriate receipt s and submit with this claim form To complete an electronic claim form or check your account balance go to Copyright 2010 WageWork s TCW W- CFHCA0310 Person for Whom Expense Incurred Total Health Care Expense Claim takecareWageWorks.

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Who uses Wageworks? CompanyWebsiteCompany SizeDailymotion SAdailymotion.com500-1000MongoDB Incmongodb.com1000-5000Regeneron Pharmaceuticals Incregeneron.com>10000NetSuite Incnetsuite.com>10000

WageWorks's top competitors include PayFlex, Forma, and Benepass. PayFlex provides employee benefits administration products and services, such as flexible spending and health savings accounts.

For more information, visit .healthequity.com. In 2019, HealthEquity and WageWorks combined to create a new health savings and consumer-directed benefits partner for employers, benefits consultants, and health and retirement plan providers seeking to help working families connect health and wealth.

You can use your WageWorks® Healthcare Card at the doctor, pharmacy, optician, and most general merchandise stores. The card transactions are usually verified automatically.

Log into your WageWorks account via the WageWorks EZ Receipts® mobile app and check your account balance. Call WageWorks Customer Service 1-877-924-3967. Provide the last four digits of WageWorks Commuter card number and your home zip code to receive your account and card balances.

Any unused pre-tax funds will be forfeited to your employer, and any post-tax funds will be refunded to you at the end of the ninety (90)-day period.

A take care® by WageWorks Healthcare Flexible Spending Account (FSA) is a pre-tax benefit account used to pay for eligible medical, dental, and vision care expenses that aren't covered by your insurance plan or elsewhere. It's a smart, simple way to save money while keeping you and your family healthy and protected.

© 2023 HealthEquity, Inc.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232