Claim form Use this form to submit your claims for reimbursement of eligible expenses paid out of pocket that have not already been submitted. • Do not use this form if expenses were already paid with your healthcare payment card. • Do not use this form if you already submitted this claim online. • Complete all entries on this submission form. Please print or type. • Sign and date this form. • Fax or mail it, along with the required documentation, to the claims department. (See submission instructions below.) Personal i nformation Name of employer Employee name (last name, first name) Social Security Number Documentation r equired You must submit documentation with this form. Documentation must include the patient’s name, description of service, date of service and amount charged. Cancelled checks, credit card receipts or balance forward statements are not acceptable. Examples of acceptable documentation include a copy of the Explanation of Benefits (EOB) from your insurance company, an itemized statement from a provider, or an itemized pharmacy receipt (if applicable to your plan). Claim Details Date of s ervice Patient’s n ame Relationship to e mployee Name of p rovider Description of s ervice Amount r equested Total $ Documentation r equired for r ecurring c laims You must include a copy of your health plan coverage letter and proof of your premium payment. Payment proof can be a cancelled check, credit card receipt, or bank statement. Request for r ecurring c laims Payment d ate Member’s name Relationship to employee/retiree Name of carrier Plan type Amount requested Self Spouse Eligible dependent Medicare Supplement Medicare Advantage Prescription Drug Plan Other health insurance Self Spouse Eligible dependent Medicare Supplement Medicare Advantage Prescription Drug Plan Other health insurance Self Spouse Eligible dependent Medicare Supplement Medicare Advantage Prescription Drug Plan Other health insurance Self Spouse Medicare Supplement Medicare Advantage