STAPLES WELLNESS CLAIM FORM PLEASE PRINT ALL INFORMATION CLEARLY MEMBER INFORMATION (Person in whose name coverage is held) UnitedHealthcare ID Number Subscribers Last Name Address Number & Street.
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How to fill out the Staples - Wellness Claim Form.doc online
The Staples - Wellness Claim Form is designed for users to request reimbursement for eligible wellness expenses. This guide will provide step-by-step instructions to help you complete the form accurately and efficiently online.
Follow the steps to successfully complete the Staples - Wellness Claim Form.
- Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Begin by filling in your member information. Enter your UnitedHealthcare ID number, subscriber’s last name, first name, middle initial, address (number and street), city, state, and zip code. Make sure all information is printed clearly.
- Gather your receipts for qualified expenses like health club memberships, weight loss programs, or fitness equipment purchases. Ensure these are 8.5 x 11 photocopies of paid receipts.
- In the ‘Information Required’ section, specify the name of the health club, weight loss program, or fitness equipment you are submitting for reimbursement. Use the provided codes for each category during submission.
- Indicate the start date of your health club membership, weight loss program, or purchase date of the fitness equipment.
- Fill out the total amount you are submitting for reimbursement in the designated area.
- Sign and date the certification and authorization section. By signing, you confirm that the information is accurate and that you have not submitted for reimbursement of these services previously during the plan year.
- Save the changes made to the form, and prepare to send the completed form along with all required attachments, such as the itemized receipts and any necessary contracts, to UnitedHealthcare at the provided address.
Complete your wellness claim form online today to ensure you receive your reimbursement.
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