Healthcare claim reimbursement form 2026

1. Click ‘Get Form’ to open the healthcare claim reimbursement form in the editor.
2. Begin by filling out the Enrollee Information section. Provide your last name, first name, primary and secondary phone numbers, People First ID, date of birth, address, city, state, and ZIP code.
3. If applicable, include information for any dependents by entering their names, relationship to you, and dates of birth.
4. In the Reimbursement Request section, clearly list your qualifying expenses. Ensure you do not include any expenses that have been reimbursed by another source. Attach copies of relevant documentation such as receipts or Explanation of Benefits (EOBs).
5. Complete the Claim Certification section by signing and dating it to confirm that all information is accurate and that you will not claim these expenses on your tax return.
6. Finally, submit your completed form along with supporting documents via fax or mail to Chard Snyder as instructed.

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