Wellmark request for reimbursement form 2025

1. Click ‘Get Form’ to open the wellmark request for reimbursement form in the editor.
2. Begin by filling out the Employee Information section. Provide your name, email address, home address, and daytime phone number. If you have a new address, check the corresponding box.
3. In the Medical Reimbursement section, attach necessary documentation such as an Explanation of Benefits or itemized receipts. Fill in details about the person receiving care, relationship, date of expense incurred, description of expense, and total reimbursement requested.
4. For Dependent Care Reimbursement, obtain your care provider’s signature or attach an itemized receipt. Include details like dependent's name, age, dates of care, and total reimbursement requested.
5. Finally, review all sections for completeness and accuracy before submitting your claim form via mail, fax, or email to Wellmark.

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