Get Health Reimbursement Account Claim Form - Myuhc.com

This guide provides a detailed walkthrough for users on how to complete the Health Reimbursement Account Claim Form online. By following the steps outlined below, users can ensure that their claims are submitted accurately and efficiently.

Follow the steps to successfully complete the claim form.

1. Click ‘Get Form’ button to obtain the claim form and open it in your preferred editing software.
2. Complete Part 1 entirely and legibly, including your employee name, Member ID, date of birth, mailing address, daytime telephone number, and employer name. If you have any changes to your address or do not know your Member ID, please contact your benefits administrator.
3. Proceed to Part 2 to itemize your health care expenses. Make sure to list each expense separately, using separate entries. You may use additional forms as needed.
4. For each expense, provide the date of service, patient's name (with the relationship to you), the date of birth, description of service, and the name and address of the provider. Also, include the provider phone number and Tax ID if available.
5. Indicate the type of service by checking the appropriate box: Medical, Prescription, Over-the-Counter, Vision, Dental, or Hearing.
6. Calculate the total request for withdrawal by summing all expenses and fill in the total amount in the designated field.
7. Read the certification for reimbursement carefully. Confirm that all provided expenses are accurate and that you have not requested reimbursement for these expenses under any other plan.
8. Sign and date the form in the certification area to confirm your agreement to the statements made.
9. Make a copy of the completed form and the supporting documentation for your records.
10. Mail (or fax) the form along with all required documentation to the Health Care Account Service Center at the address provided on the form. Ensure your submission is made before the specified filing deadline.

Start filling out the Health Reimbursement Account Claim Form online today!