Get Acclarisonline

This guide provides step-by-step instructions for completing the Acclarisonline form, ensuring you accurately submit your reimbursement requests for health care expenses. Follow these detailed instructions to navigate the form effectively and ensure a smooth submission process.

Follow the steps to accurately complete your reimbursement request

1. Press the ‘Get Form’ button to access the reimbursement request form and open it in the designated editor.
2. Fill in the 'Date of Service' field with the exact date when the medical service was provided.
3. Provide the full name of the service provider, including clinics, doctors, pharmacies, or stores, in the 'Service Provider' section.
4. In the 'Description of Expense' field, specify the type of service received or the name of the medication prescribed.
5. Enter the total amount paid for the service in the 'Amount Paid' section, detailing the complete cost incurred.
6. If insurance covered any part of the expense, indicate that amount in the 'Amount Paid By Insurance' field.
7. Record the amount you personally paid in the 'Amount Paid By You' section.
8. If needed, you may attach additional pages to include more expenses, ensuring each adheres to the required format.
9. Calculate the total unreimbursed health care claim and document this amount in the 'Total Unreimbursed Health Care Claim' section.
10. For mileage reimbursement related to medical travel, fill in the 'Mileage' field and the corresponding 'Date of Service'.
11. Review the certification section and sign to agree that all information is accurate and complete.
12. Finally, save your changes, and use the options available to download, print, or share the completed form.

Complete your documents online to ensure timely processing of your health care reimbursement requests.