Submit a Claim 提交索赔

Enter your claim below and attach the receipt. You will get a confirmation number — keep it to check your claim status. 在下方填写索赔并附上收据。您将获得一个确认号——请妥善保管以查询索赔状态。

Plan access code 计划访问代码

The office gave you this code when you enrolled. Not sure? Ask the office. · 报名时办公室给您的代码。不确定？请问办公室。

Employee name 员工姓名 Your company 您所在的公司 Account type 账户类型 Date of service 服务日期 Amount ($) 金额（美元） Provider name 服务提供者名称 Description 说明 Receipt (PDF, JPG, or PNG, up to 10 MB) 收据（PDF、JPG或PNG，最大10 MB）

A clear phone photo of the receipt is fine. · 用手机拍一张清晰的收据照片即可。

The receipt should show the provider, the patient, the date, the service, and the amount. For items marked [CONDITIONS] on the Eligible Expenses page, also keep the prescription or doctor's letter of medical necessity — the office may ask for it. 收据应注明提供者、患者、日期、服务和金额。对于"合资格费用"页面上标有[有条件]的项目，请同时保留处方或医生的医疗必要性证明信——办公室可能会要求提供。