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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 compl....

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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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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232