HEALTH CARE ACCOUNT
Claim Form & Filing Instructions
On the reverse side of this page is a claim form. Please feel free to copy this form.
When ling your claim, you must attach copies of the receipts. The receipt must show
the date and type of service for the expense. Canceled checks, credit card slips, or
statements showing only a balance due on your account are not allowable.
Please be sure to number each attachment page (e.g., Page 2 of 3, Page 3 of 3, etc.).
• Fax: For faster service, fax your claim with receipts to 877-782-8889. Your claim
form is your fax cover page. After you fax a claim with receipts, please do not
follow up with a postal mail or email.
• Email: For even faster service, scan your claim form with receipts into a single
PDF. Your claim form should be the rst page of your scan. Email the PDF to
email@example.com. After you email a claim with receipts, please do
not follow up with a postal mail or fax.
• PostalMail: If you don’t use email or fax, postal mail your claim with receipts to
take care by WageWorks, PO Box 14054, Lexington, KY 40512.
Remember to keep the original claim form and supporting documents for your records.
To verify your claim has been received, go to the website described below. When
your claim is approved, it will appear within three business days on the website
under “View Account.”
You may check your account balance status any time, day or night at the website.
In addition, the website has a claim form, a list of qualifying expenses, and other
administrative tools that will help you conveniently manage your account. The site
also has frequently asked questions and instructions on how to contact us.
…everything you need to manage
your Flexible Benet Account…
• Verify your election
• View your account balance
• Complete electronic claim form
• How and where to le claims
• Look up qualied expenses
• Change in status rules
• Eligibility requirements
• Learn about the plan
• How to contact us
Copy the front and back of this claim form for future use.
© 2011 WageWorks, Inc. All rights reserved. TCWW_4527_CF_HCA (Apr 2011)