Com to submit your claim electronically with uploaded documentation 2025

1. Click ‘Get Form’ to open it in the editor.
2. Complete all account holder information, including your last name, first name, employer, and ID code (last 4 digits of your Social Security number).
3. Use your documentation to fill in each section of the form. Start with the provider's name and service dates.
4. Enter the patient’s name along with their relationship to you (self, spouse, qualifying child, etc.) and specify the type of service received.
5. List the out-of-pocket costs for each service provided. Ensure that all entries are accurate and legible.
6. If applicable, have your provider sign the form to confirm services rendered, which can replace separate documentation.
7. Review all information for completeness before submitting your claim electronically through our platform.

Start using our platform today for a seamless claim submission experience!