Hpffa 341 supplmental claim form 2026

1. Click ‘Get Form’ to open the hpffa 341 supplemental claim form in the editor.
2. Begin by selecting the applicable health plan from the options provided: CKC, OAP, CDHP, or Medicare Retiree Plan. This helps categorize your claim correctly.
3. Fill in your personal details including Member Name, Birth Date, and the last four digits of your Social Security Number. Ensure accuracy for smooth processing.
4. Provide your address information. If you have a new address, check the corresponding box to update your records.
5. List any dependents for whom you are filing a claim by entering their Full Name and Birth Date. Specify the relationship to you (e.g., Spouse, Child).
6. Sign and date the form at the bottom to validate your submission. Remember that submitting false information can lead to serious consequences.
7. Attach all original receipts and any necessary documentation before submitting your claim to ensure it is processed without delays.

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