Usable claim forms 2026

1. Click ‘Get Form’ to open the Wellness Benefit Request Form in the editor.
2. Begin by filling out your personal information. Enter your name, Social Security Number, birth date, best phone number, email address, and home address in the designated fields.
3. Next, provide your employer information. Fill in the employer's name and group policy number.
4. In the Patient Information section, enter the patient's details including their name, Social Security Number, and birth date.
5. Select the test or service performed from the list provided. Indicate your relation to the insured by checking the appropriate box (Self, Spouse, Dependent).
6. Fill in the Provider of Test/Service section with details about where the test was performed. Include the name of the medical facility and performing physician’s name along with the date performed.
7. Finally, sign and date the form at the bottom. Ensure you provide a contact number for any follow-up.

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