Optumclaims prod sourcehov com 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'About You' section. Enter your First Name, Last Name, Last 4 of SSN, Employer/Plan Sponsor Name, and Participant Address.
3. In the 'About Your Expenses' section, list each healthcare expense on a new line. For multiple expenses of the same type, you can combine them into one line for the entire date range.
4. For each expense, provide the Date of Service (MM/DD/YY), Expense Amount Claimed, Name of Person Receiving Service, Name of Service Provider, and Type of Expense (e.g., Medical, Vision).
5. Complete the Dependent Care Expenses section similarly by entering details for each dependent receiving service.
6. In the Provider Certification area, include your name and total amount claimed. Ensure you sign and date the form at the bottom.
7. Attach any required supporting documentation before submitting your form via mail or email as specified.

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