WageWorks Pay Me Back Claim Form Instructions - Cook County ... 2026

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Click ‘Get Form’ to open the WageWorks Pay Me Back Claim Form in the editor.
Begin by filling in your personal information, including your legal name as recorded by your employer, ID code, and contact details. Ensure accuracy to avoid processing delays.
In the claims section, list each out-of-pocket expense. For every entry, specify the type of service (e.g., dental, vision) and include the corresponding cost. Remember to provide the service start date.
Attach receipts for each expense claimed. Ensure that receipts are clear and include dates of service. Circle or check the claimed amount on each receipt but avoid using highlighters.
Review all fields for completeness before signing at the bottom of the form. Your signature certifies that all information is accurate and that you have not sought reimbursement from other sources.
Submit your completed form via fax or mail as instructed, ensuring no cover page is used if faxing.

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