HEALTH CARE ACCOUNT
PAY ME BACK CLAIM FORM
TOLL-FREE FAX: 877-782-8889
Email: claims
@
takecareclaims.com
Or mail to take care by WageWorks, PO Box 14054, Lexington, KY 40512
ACCOUNT HOLDER INFORMATION
Last Name First Name
Social Security Number Employer / Program Sponsor’s Name
_________________________________________________________________
Zip Code Birth Month/Day (MM/DD) Email Address (complete only if new)
CERTIFICATION AND AUTHORIZATION
The undersigned participant in the Plan certifies that all services for which reimbursement or payment is claimed by submission of
this form were provided during a period while the undersigned was covered under the Company’s Flexible Benefit Plan with respect to
such expenses and that the medical expenses have not been reimbursed and that the undersigned will not seek reimbursement under any
other health plan coverage. The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy, and
veracity of all information relating to this claim which is provided by the undersigned, and that unless an expense for which payment or
reimbursement is claimed is a proper expense under the Plan, the undersigned may be liable for payment of all related taxes including
federal, state, or city income tax on amounts paid from the Plan which relate to such expense.
________________________________________________________________ ___________________________________________
Employee’s Signature Date
UNREIMBURSED MEDICAL EXPENSE CLAIMS
Date Expense
incurred
(mm/dd/yy)
Name of Service Provider Expense Description Person for Whom
Expense Incurred
Net Amount
Attach appropriate receipt(s) and submit with this claim form
Total Health Care Expense Claim
To ensure speedy processing:
DO NOT USE A FAX COVER SHEET
takecareWageWorks.com
To complete an electronic claim form
or check your account balance go to
© 2011 WageWorks, Inc. All rights reserved. TCWW_4527_CF_HCA (Apr 2011)
$0.00
take care
®
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
claims@takecareclaims.com. After you email a claim with receipts, please do
not follow up with a postal mail or fax.
• PostalMail: 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.
takecareWageWorks.com
…everything you need to manage
your Flexible Benet Account…
• Verify your election
• View your account balance
• Complete electronic claim form
• How and where to le claims
• Look up qualied 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)
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