Follow the steps to complete your health reimbursement claim form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin filling in your participant information. This includes your last name, first name, OEF number or Social Security Number (SSN), and full address including street number, city, state, and zip code.
3. Provide your email address on the claim form. This allows the Health Fund to notify you once your claim has been received and provide an estimate of processing time.
4. Enter the total reimbursement amount for each family member involved on the appropriate lines. It is important that you do not itemize expenses for each person.
5. Attach copies of any required documentation, such as the blue Explanation of Benefit (EOB) forms from the Health Fund, prescription receipts, or receipts for services not covered. Do not submit balance due statements from doctors' offices or hospitals.
6. Confirm that your total HRA claim amount is $250 or more. Claims under this amount will be held until you submit additional receipts.
7. Complete the participant authorization section by signing and dating the form. Your signature certifies that the reimbursement request is valid and compliant with the Health Fund's guidelines.
8. Once completed, review the form for accuracy. Save any changes made to the form, then download or print a copy for your records.
9. Submit the claim form along with all necessary documentation to the Operating Engineers Local 139 Health Benefit Fund at the provided address.

Take action now: complete your Iuoe 139 Health Fund reimbursement claim form online today!