Get Oneexchange Reimbursement Request Form - Ibew 965

This guide provides step-by-step instructions on how to complete the OneExchange Reimbursement Request Form - IBEW 965 online. Whether you are a retiree or a covered participant, this comprehensive guide will help you navigate the form with ease.

Follow the steps to complete the reimbursement request form accurately.

1. Press the ‘Get Form’ button to retrieve the OneExchange Reimbursement Request Form - IBEW 965 and open it for editing.
2. In the Account Holder Information section, enter the name of the account holder, typically the retiree or surviving spouse. Make sure to provide the last name, first name, and middle initial as needed.
3. Fill out the Reimbursement Request Information section. Indicate the covered participant's name, their relationship to the account holder, the date of service in MM/DD/YY format, the type of coverage (like medical), and the total amount you are requesting reimbursement for.
4. Carefully read the Certification Requirements. Ensure that the information you provided is correct and that the expenses were incurred under the plan on or after its effective date.
5. For premium reimbursement requests, include necessary third-party documentation that certifies your request, such as a premium statement and proof of payment, ensuring the payment amount matches the premium statement.
6. For out-of-pocket expenses like copays or deductibles, gather supporting documentation from third-party providers that confirm the service details, including the provider's name, date of service, and amount paid.
7. Double-check that all required information is included, especially for documentation that verifies your claims. If using a handwritten receipt, ensure it bears the service provider's signature.
8. Upon completion, save your changes. You can then choose to download, print, or share the form as necessary.

Get started today by filling out your OneExchange Reimbursement Request Form - IBEW 965 online!