What is the password for Illumina SBS admin?

2 Type the default password, sbs123, in the Old password field. 3 Type a new password in the New password field. Consult your IT administrator for guidance on password complexity. Illumina recommends a password that is at least 10 characters and contains numbers, letters, and symbols.

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Mail to SBS Administrative Services P O Box 380768 San Antonio TX 78268 Email sbsclaims sbsadmin.com Fax to 210-659-8171 Health Reimbursement Arrangement Claim Form SECTION 1 EMPLOYEE INFORMATION Please Print Name SSN Address Day Phone City State Zip Employer Email Address This may be used to contact you if additional information is required for your claim and we are unable to reach you by phone. SECTION 2 Health Reimbursement Arrangement Attach Explanation of Benefits Make sure you attach an Explanation of Benefits EOB Person for Whom Expense was incurred An EOB MUST be provided which shows the date of service and the eligible amounts applied to your deductible. SBS will only process reimbursement for expenses with a supporting EOB and for those expenses you are claiming on this claim form* Incomplete claims will be returned to you. Date of Service Name of Provider Description of Amount Total Unreimbursed Deductible Expenses I certify that all expenses requested to be reimbursed comply with my employer s Health Reimbursement Arrangement Plan and such expenses have not and will not be covered under any other plan or program of any employer or other person* I further certify that if such expenses are reimbursed to me by a provider or any other entity I will promptly reimburse the Plan* The Plan Administrator does not accept responsibility for direct payment to any individuals other than the employee. Employee Signature Date Visit us on the Web www. sbsadmin*com FOR HELP CONTACT OUR CUSTOMER SERVICE TEAM 210 659-8100 or 888 659-8151. SECTION 2 Health Reimbursement Arrangement Attach Explanation of Benefits Make sure you attach an Explanation of Benefits EOB Person for Whom Expense was incurred An EOB MUST be provided which shows the date of service and the eligible amounts applied to your deductible. SBS will only process reimbursement for expenses with a supporting EOB and for those expenses you are claiming on this claim form* Incomplete claims will be returned to you. SBS will only process reimbursement for expenses with a supporting EOB and for those expenses you are claiming on this claim form* Incomplete claims will be returned to you. Date of Service Name of Provider Description of Amount Total Unreimbursed Deductible Expenses I certify that all expenses requested to be reimbursed comply with my employer s Health Reimbursement Arrangement Plan and such expenses have not and will not be covered under any other plan or program of any employer or other person* I further certify that if such expenses are reimbursed to me by a provider or any other entity I will promptly reimburse the Plan* The Plan Administrator does not accept responsibility for direct payment to any individuals other than the employee. Date of Service Name of Provider Description of Amount Total Unreimbursed Deductible Expenses I certify that all expenses requested to be reimbursed comply with my employer s Health Reimbursement Arrangement Plan and such expenses have not and will not be covered under any other plan or program of any employer or other person* I further certify that if such expenses are reimbursed to me by a provider or any other entity I will promptly reimburse the Plan* The Plan Administrator does not accept responsibility for direct payment to any individuals other than the employee. Employee Signature Date Visit us on the Web www. sbsadmin*com FOR HELP CONTACT OUR CUSTOMER SERVICE TEAM 210 659-8100 or 888 659-8151.

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