Get Grace / Mayer Flex Claim Form - Mymosaicinfo.org - Mymosaicinfo

Filling out the GRACE / MAYER FLEX CLAIM FORM accurately is essential for processing your claims efficiently. This guide will provide you with clear, step-by-step instructions to assist you in completing the form effectively, ensuring you include all necessary information.

Follow the steps to complete your claim form successfully.

1. Click the ‘Get Form’ button to access the claim form and open it in your preferred document editor.
2. Begin by entering your name in the 'Employees' Name' section. Provide your last name, followed by your first and middle names.
3. If you have a new address, check the corresponding box to indicate this change.
4. Enter your social security number in the designated field to ensure identification.
5. Fill in your street address, including the city, state, and ZIP code.
6. Provide the name of your employer in the specified section.
7. In the 'Medical Care Expenses' section, list any eligible expenses not covered by insurance. Ensure to attach an itemized statement or an Explanation of Benefits if applicable.
8. For each medical expense, fill out the date of service, patient name, your relationship to the patient, provider name, description of service, and the amount requested.
9. If you are claiming dependent care expenses, make sure your provider signs and completes the appropriate section, and note that no claim receipts are required in this case.
10. In the 'Dependent Care Expenses' area, provide the dates of care, dependent name, age, provider signature, provider address, and their tax identification number or social security number.
11. Finally, read the certification statement carefully, sign where indicated, and include the date of your signature.
12. Once all fields are completed, save your changes, and then you can download, print, or share the completed form as needed.

Start filling out your GRACE / MAYER FLEX CLAIM FORM online today.