Fillable Choice Claim Form (Page 2 of 2) in pdf

Health Care Account

Pay Me Back Claim Form

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File claim online - Join the growing majority of participants who submit their claim

online for faster service. Log in to your account at to file your

claim electronically and upload your documentation.

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File claim via fax, mail, or email - Claim forms may also be filed either via fax or US Mail

and sent to the following locations: Fax: 877-723-0148, US Mail: Choice Strategies, P.O. Box

2205, South Burlington, VT 05407, Email:

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Claim processing time - Claims will be processed within 2 business days after Choice

Strategies receives the form. You may check the status of your claim by logging into your

account at .

ACCOUNT HOLDER:

Last Name

First Name

Employer Name

* ID Code is the last 4 digits of your Social Security Number, your Employee ID number or other reference number

assigned by your employer. Please check the enrollment instructions provided by your program sponsor for more

information about your ID Code.

ID Code*

Zip Code

SERVICE DATES

PATIENT NAME, RELATIONSHIP TO ACCOUNT HOLDER

PROVIDER NAME

CLAIM

(Start and End Dates)

AND TYPE OF SERVICE

(MM/DD/YY)

Patient Name: _______________________________________________________

Relationship to Account Holder:

Type of Service:

Self

Spouse

Qualifying Child

Qualifying Relative

Other: __________________

Patient Name: _______________________________________________________

Relationship to Account Holder:

Type of Service:

Self

Spouse

Qualifying Child

Qualifying Relative

Other: __________________

Patient Name: _______________________________________________________

Relationship to Account Holder:

Type of Service:

Self

Spouse

Qualifying Child

Qualifying Relative

Other: __________________

Patient Name: _______________________________________________________

Relationship to Account Holder:

Type of Service:

Self

Spouse

Qualifying Child

Qualifying Relative

Other: __________________

More expenses? Please complete another form.

CLAIM FORM TOTAL:

0 . 0 0

CERTIFICATION AND AUTHORIZATION:

I certify that the information on this form is accurate and complete. I am requesting reimbursement for eligible deductible 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 already received these products and services

and confirm that by requesting reimbursement here that I 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 website. Use of this service indicates my acceptance of

the WageWorks User Agreement at (available upon registration; enter username and password or click on First Time User? link).

CSWW-HC-PMB (Oct 2014)