Follow the steps to accurately complete your claim form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. Begin by entering the insured person's name in the 'Insured Name' field.
3. Complete the address section: fill in the address, city, state, and zip code.
4. Provide the last four digits of the Social Security number of the insured individual in the designated field.
5. Enter the employer's name in the 'Employer's Name' section.
6. Specify the requested reimbursement amount in the 'Requested amount' field clearly.
7. Indicate the preferred reimbursement option by checking either 'Reimburse me' or 'Pay provider'.
8. Clearly state if you want AHR to negotiate a better price by selecting 'Do not negotiate a better price for me'.
9. In the 'Provider Name' field, enter the name of the medical provider.
10. Provide the patient's name in the 'Patient Name' section.
11. The employee must sign in the 'Employee Signature' field.
12. Complete the provider's address, city, state, and zip code.
13. Include the provider's phone number and account number to ensure accurate processing.
14. Attach copies of bills or Explanation of Benefits (EOB) to substantiate your request for reimbursement.
15. Review all the information you've provided for accuracy and completeness.
16. Once complete, save your changes, and then download, print, or share the form as needed.

Take the next step and complete your claim form online for a quicker process.