Follow the steps to complete your claim form online.

1. Click 'Get Form' button to obtain the form and open it in an online editor.
2. Enter your name in the designated field, beginning with your last name followed by your first name and middle initial.
3. Input your Social Security Number in the corresponding section.
4. Fill out your address, ensuring you include street address, city, state, and zip code.
5. Provide your daytime telephone number for any follow-up needed.
6. In the 'Employer' section, enter the name of your employer as it appears on official documents.
7. For health care claims, specify the date of service using the format mm-dd-ccyy.
8. Indicate the service provider's name and type of service from the given options, such as prescription or dental.
9. List the requested amount for each service received and calculate the health care total.
10. For dependent care claims, note the dates of service and the name of the care provider.
11. Include the dependent's name and requested amounts associated with dependent care services.
12. If opting for provider certification, have the provider fill out their signature, date, and tax ID information.
13. Certify that the information provided is accurate by signing the employee certification section.
14. Save your changes, and prepare to download or print the completed form.
15. Once the form is filled out and saved, attach original receipts and either fax or mail your claim to the provided address.

Start completing your 18882119900 form online today for a smoother claims process!