To ensure we are able to process your reimbursement, please fully complete the WageWorks Pay Me Back Claim Form - wageworks 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out all account holder information, including your last name, first name, employer name, ID code (last four digits of your Social Security Number or Employee ID), and zip code.
3. In the 'Provider Name' section, enter the name of the healthcare provider. Include service dates in MM/DD/YY format.
4. For each patient listed, provide their name, relationship to you (the account holder), type of service received, and out-of-pocket costs. Ensure that all documentation is legible and accurate.
5. If applicable, have your provider sign the form where indicated. This signature can replace other proof of service.
6. Review all entries for completeness before submitting. You can submit your claim electronically through our platform or print and send it via fax or mail.

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