Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to acquire the form and open it in the online editor.
2. Review the member identification number section and enter your unique member ID as provided by your employer.
3. Fill in your employer's name in the designated field to ensure the reimbursement is processed through the correct organization.
4. Complete the employee’s name section by entering your last name, first name, and middle initial in the corresponding fields.
5. In the employee’s address section, provide your current street address, city, state, and ZIP code to confirm your location.
6. Enter your telephone number and email address in the appropriate fields to ensure that the administration can reach you for any inquiries.
7. Attach any necessary documentation for your reimbursement request; remember that cash register receipts are not acceptable. Use the Explanation of Benefits if available.
8. If you wish to receive payment directly to your healthcare provider, mark the designated box.
9. Sign the form where indicated to certify that all information provided is correct and complete.
10. Fill out the reimbursement request section, detailing the patient’s name, date of service, service description, and the amount you are claiming.
11. Specify whether the amount billed was filed under your flexible spending account by selecting 'Yes' or 'No'.
12. Once all fields are completed, save changes to the form. You can opt to download, print, or share your filled form as needed.

Begin filling out your reimbursement claim online to secure your benefits efficiently.