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How to File a Claim

You can print a claim form from this website. All expenses must be itemized on the claim form, along with a signature and date.

All expenses must include the following supporting documentation:

  1. Date of Service
  2. Type of Service performed
  3. Provider's Name
  4. Amount of Charges
  5. For Prescription expenses, the Rx # or name of prescription must be included with all of the above.
  6. For Dependent Care expenses, the provider's Tax ID or social security number must be included with all of the above.

Acceptable types of Supporting Documentation Include:

  1. Itemized billing statement from provider with dates of service and types of service performed.
  2. Explanation of Benefit from your insurance company
  3. Receipt from provider with all information above

Unacceptable (per the IRS) types of Supporting Documentation include:

  1. Canceled checks or copies of checks
  2. Credit card receipts or billing statements
  3. Balance forward or previous balance statements
  4. Estimates of services to be incurred.
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