Get A Printable Win Reimbursement Form - Dean Health System

The A Printable WIN Reimbursement Form allows eligible DeanCare Gold and DeanCare Select members of Dean Health Plan to receive reimbursement for various health-related activities. This guide will provide detailed instructions to assist you in accurately completing the form online.

Follow the steps to fill out the reimbursement form effectively.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Select the services for which you are claiming reimbursement by checking the applicable boxes, including acupuncture, health club memberships, exercise classes, or weight management programs. Ensure you read any specific instructions regarding each service.
3. If claiming for acupuncture services, remember to include the licensed professional's license number.
4. Attach proof of payment for each selected service. This could be a receipt or other documentation verifying the amount paid.
5. Enter the date of service in the specified field, ensuring it corresponds with your proof of payment.
6. Fill in the total amount corresponding to the proof of purchase for reimbursement.
7. Provide member details, including the name of the member receiving the service, member number (11-digit number), date of birth, and complete address including street, city, state, and ZIP code.
8. Review all entered information for accuracy. Ensure all required fields are completed and supporting documentation is included.
9. Once you have filled out the form, save your changes. You can then download, print, or share the completed form as needed.

Complete your WIN reimbursement form online today for quick processing of your health-related reimbursements.