Get Reimbursement Account Claim Form

Filing a reimbursement claim online can be a straightforward process when you have the right guidance. This guide will walk you through each section of the reimbursement account claim form to ensure that you complete it correctly and efficiently.

Follow the steps to accurately complete your reimbursement account claim online.

1. Click ‘Get Form’ button to access the reimbursement account claim form and open it in your preferred online editor.
2. Begin by entering your member identification number, which is either your employer assigned number or W ID. This helps in accurately identifying your claim.
3. Provide your full name by filling in the last name, first name, and middle initial. This section ensures that the form is correctly attributed to you.
4. Fill out your complete address, including the street, city, state, and ZIP code. If you have had an address change, make sure to notify your employer.
5. Indicate your employer's name in the designated field to clarify your employment status.
6. List any health care expenses incurred for you, your partner, and any dependents. Specify if you, your partner, or any dependent has additional coverage under another plan.
7. If you are requesting reimbursement for orthodontia expenses, check the automatic monthly reimbursement box and include a copy of your orthodontia contract.
8. Detail each type of service that you are claiming (e.g., deductible, dental, medical, etc.), along with the patient's name and dates of service.
9. Enter the exact amount requested for each service provided, ensuring accuracy in total amounts.
10. For dependent care expenses, provide the exact dates of service and caregiver information. Ensure to certify the services provided by your caregiver through their signature.
11. Review and sign the certification statement, confirming that the expenses are valid and have not been reimbursed elsewhere.
12. Finally, you can choose to save changes, download a copy, print, or share the completed form as needed.

Take the first step to manage your finances by filling out your reimbursement account claim form online today.