Get Wageworks Healthcare Account Pay Me Back Claim Form 2017-2025

The WageWorks HealthCare Account Pay Me Back Claim Form allows users to request reimbursement for eligible healthcare expenses. This guide provides step-by-step instructions to ensure successful completion of the form online.

Follow the steps to fill out the form accurately.

1. Click the ‘Get Form’ button to access the WageWorks HealthCare Account Pay Me Back Claim Form and open it in your preferred online editor.
2. Begin by completing all account holder information. This includes your last name, first name, and employer name, ensuring that the employer name is written in full without abbreviations.
3. Enter your ID code. This is the last four digits of your Social Security number, your Employee ID number, or another reference number assigned by your employer as outlined in the enrollment instructions.
4. Fill in the provider name and zip code. This identifies the healthcare provider from whom you received services.
5. Document the service dates. Input the start and end dates in the format MM/DD/YY to indicate the period in which the services were provided.
6. For each expense, input the patient name, relationship to the account holder, type of service, and the out-of-pocket cost. Select the appropriate type of service from the provided options and ensure that the costs are correctly totaled.
7. If there are more expenses to report, repeat the process for additional patients and services. Ensure the total amount of all claims is accurately calculated at the bottom of the form.
8. Review your entries carefully to confirm that all information is accurate and complete. This prevents delays in the claims process.
9. Submit your form electronically. Follow the online submission instructions to finalize your claim, ensuring that all required documentation is uploaded.

Start completing your WageWorks HealthCare Account Pay Me Back Claim Form online today for a smoother reimbursement experience.