Get Wageworks Health Care Pay Me Back Claim Form - Mybenefits Trinity-health

This guide provides a clear, step-by-step process for filling out the WageWorks Health Care Pay Me Back Claim Form. By following these instructions, users can ensure that they provide all necessary information for a successful claim submission.

Follow the steps to accurately complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Complete all account holder information, including your last name, first name, employer name (in full), ID code (last four digits of your Social Security Number or assigned by your employer), and zip code.
3. Enter the service date(s) for the medical services received, following the MM/DD/YY format.
4. Provide the name of the provider who rendered the services. If available, a provider's signature can replace other proof of service.
5. Fill in the patient information for each service, including the patient's name, their relationship to the account holder, type of service, and out-of-pocket cost.
6. If there are additional expenses, you may complete another form. Ensure clarity and legibility as you complete each section.
7. Review the certification and authorization statement at the bottom of the form. By signing, you confirm that the information provided is accurate and you are seeking reimbursement for eligible expenses only.
8. Once all information is filled out and verified, save any changes, and prepare to submit the form online or through available means such as fax or mail.

Take action today and submit your claims online for a more efficient processing experience.