© 2024 Optum, Inc. All rights reserved. 136897B-052024 � Eligible dependent � Prescription Drug Plan � Other health insurance Total All recurring claims will pay at the same payment frequency. Use separate forms to set different payment schedules. _____ One time payment _____ Monthly automatic recurring payments (Documentation does not need to be provided for future months, unless the premium amount changes.) _____ If monthly automatic recurring, provide final reimbursement date. Date will default to the end of the current calendar year. You will need to submit a new claim for the new calendar year if you wish to continue reimbursements after 12/31. Authorization and certification Read carefully: This claim will not be processed without your signature. I certify that these expenses have been incurred by me, my spouse or my eligible dependent. The expenses have not been reimbursed and are not reimbursable under any other plan, such as an individual policy or my spouse’s or dependent’s plan. I understand that any amount reimbursed may not be used to claim any federal income tax deduction or credit on my or my spouse’s income tax return. I attest that this submission is not a reimbursement for health insurance premiums paid by pre-tax payroll deduction. Signature Date Submission instructions For fastest results, fax to: 1-443-681-4601 Or mail to: Claims service center P.O. Box 622337 Orlando, FL 32862-2337 If you have any questions, please contact Customer service at 1-877-554-1004, option 2.