ACCOUNT HOLDER INFORMATION
Last Name First Name
Employer / Program Sponsor's Name
)wen fi ylno etelpmoc( sserddA liamEedoC piZ
CERTIFICATION AND AUTHORIZATION
etaDX redloH tnuoccA fo erutangiS
CLAIMS FOR OUT-OF-POCKET EXPENSES
INCOMPLETE FIELDS MAY RESULT IN YOUR CLAIM BEING DENIED
1 $
redloH tnuoccA ot pihsnoitaleRemaN s'tneitaP
2 $
redloH tnuoccA ot pihsnoitaleRemaN s'tneitaP
3 $
redloH tnuoccA ot pihsnoitaleRemaN s'tneitaP
4 $
redloH tnuoccA ot pihsnoitaleRemaN s'tneitaP
5 $
redloH tnuoccA ot pihsnoitaleRemaN s'tneitaP
YOU MUST ATTACH APPROPRIATE PROOF OF SERVICE FOR EACH AMOUNT ABOVE.
$
MORE EXPENSES? Complete another form.
Service Start Date (MM/DD/YY)
ID Code (last 4 digits)
*
Service Start Date (MM/DD/YY)
Service Start Date (MM/DD/YY)
Service Start Date (MM/DD/YY)
Service Start Date (MM/DD/YY)
Birth Month/Day (MM/DD)
Out-of-Pocket Cost
Out-of-Pocket Cost
TOTAL THIS FORM
Out-of-Pocket Cost
Out-of-Pocket Cost
Out-of-Pocket Cost
Health Care Accoun
Pay Me Back Claim Form
Rx Dental Psych / therapy Ortho
Co-payment Over-the-counter Chiro Hospital
Office visit Vision Lab X-ray
Other: __________________________________________________________
Rx Dental Psych / therapy Ortho
Co-payment Over-the-counter Chiro Hospital
Office visit Vision Lab X-ray
Other: __________________________________________________________
Rx Dental Psych / therapy Ortho
Co-payment Over-the-counter Chiro Hospital
Office visit Vision Lab X-ray
Other: __________________________________________________________
Rx Dental Psych / therapy Ortho
Co-payment Over-the-counter Chiro Hospital
Office visit Vision Lab X-ray
Other: __________________________________________________________
Rx Dental Psych / therapy Ortho
Co-payment Over-the-counter Chiro Hospital
Office visit Vision Lab X-ray
Other: __________________________________________________________
I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible expenses incurred by myself or an eligible dependent
while I was a participant in the plan. (Patient & Relationship is assumed to be Self unless otherwise indicated.) I have alread
received these products and services
and have not and will not seek reimbursement of this expense from any other plan or party. If I am covered under more than one health care account, reimbursement will be
made according to the payment order determined by those plans and as stated on the WageWorks Web Site. Use of this service indicates my acceptance of the
WageWorks User Agreement at www.wageworks.com (available upon registration; enter user name and password or click on First Time User? link).
TOLL-FREE FAX: (877) 353 - 9236
Or, mail to: Claims Administrator, PO Box 14053, Lexington, KY 40512
Self Qualifying Child
Spouse Qualifying Relative
Other: _______________________
Self Qualifying Child
Spouse Qualifying Relative
Other: _______________________
Self Qualifying Child
Spouse Qualifying Relative
Other: _______________________
Self Qualifying Child
Spouse Qualifying Relative
Other: _______________________
Self Qualifying Child
Spouse Qualifying Relative
Other: _______________________
DO NOT USE A FAX
COVER SHEET
to ensure speedy processing.
www.wageworks.com
WW-HC-0907-PMB
*
Your ID Code is the last 4 digits of your Social Security Number, your Employee Number or other reference
number assigned by your program sponsor. Please check the enrollment instructions provided by your program
sponsor for more information about your ID Code.
