Follow the steps to fill out the Claim Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Start by entering your name and employer's name in the designated fields at the top of the form. This information identifies you and your affiliation.
3. Provide your email address and Social Security Number (SSN) to facilitate communication and verification.
4. Fill in your address and daytime phone number for any follow-up communications regarding your claim.
5. Indicate the plan year for which you are submitting the claim. This helps in processing your request appropriately.
6. Under the Health Care Expenses section, list the Date of Service, Account type (such as FSA or HRA), Type of Service, and Patient name for each claim being submitted.
7. Calculate and enter the Total Claims amount for health care expenses in the designated box.
8. Move to the Dependent Care Expenses section, where you will enter the relevant dates (From and To) and the amount for each dependent care claim.
9. Specify the name of the dependent and fill in the total claims amount for dependent care expenses.
10. If applicable, provide the Daycare Provider Information, including the provider's name and signature. This is necessary only if you do not have a receipt from the provider.
11. Review the certification statements, confirming that all expenses meet the requirements for reimbursement. This confirmation is essential for compliance.
12. Finally, sign and date the form to certify that the information provided is accurate and complete. This step is crucial for the processing of your claim.
13. Once you have filled out all sections, you can save your changes, download the form, print it for your records, or share it as needed.

Start completing your Claim Form - - Rocky Mountain Reserve online today to ensure timely processing of your claims.