Optumclaims prod sourcehov com 2025

1. Click ‘Get Form’ to open the optumclaims prod sourcehov com document 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 expense type on a new line. For multiple expenses of the same type, you can combine them for a date range.
4. For each healthcare 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 providing details for each dependent receiving service.
6. In the Agreement and Signature section, read through the certification statement carefully before signing and dating it.
7. Attach any required supporting documentation before submitting your form via mail or email as specified at the end of the document.

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