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 information Name of employer Employee name (last name, first name) Social Security Number Documentation required 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 service Patient’s name Relationship to employee Name of provider Description of service Amount requested Total $ Documentation required for recurring claims 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 recurring claims Payment date 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