Get To Send Scanned Claims, Or For Additional Forms, Go To

Filling out the To Send Scanned Claims, Or For Additional Forms is a straightforward process that ensures you can submit your reimbursement requests efficiently. This guide will walk you through each section of the form to help you complete it accurately and effectively.

Follow the steps to complete your reimbursement request form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in your employer's name clearly in the designated space.
3. Indicate the total number of pages you are submitting in the appropriate field.
4. Provide your name and employee ID. This can be your Social Security number or an assigned alternate ID.
5. Enter your phone number, ensuring it has the correct format.
6. If you would like to confirm receipt, check the box indicating 'Yes'.
7. In the comments section, you may provide any additional relevant information.
8. List the eligible expenses for medical, dental, or vision services. Be sure to include only the amounts you have out-of-pocket after insurance has paid.
9. For each type of expense (medical, prescription, vision, dental, orthodontia), fill in the corresponding sections with the service dates and amounts requested.
10. Calculate the total reimbursement requested and ensure it is clearly indicated at the bottom of the form.
11. Gather and attach the required documentation, such as the explanation of benefits from your insurance if applicable.
12. Review the entire form for accuracy, then sign where indicated, confirming that the expenses submitted are valid and have not been reimbursed previously.
13. If your address has changed, complete the new address section.
14. Finally, save your changes, then download or print the completed form for submission.

Start completing your reimbursement request online today!