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Rev.09/16 STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION Princess Keelikolani Building 830 Punchbowl Street Room 209 Honolulu Hawaii 96813 FORM HC-5 EMPLOYEE NOTIFICATION TO EMPLOYER FOR CALENDAR YEAR 2017 Instructions to employer See employee s selection below and take appropriate action. Keep this completed signed form and give a copy to the employee. You must keep this form for 2 years. The employee s selection below is applicable only within...
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How to fill out hc 5 2017 form:
01
Obtain the hc 5 2017 form from a designated source, such as a healthcare provider or insurance company.
02
Carefully read the instructions provided with the form to understand the purpose and requirements.
03
Begin by filling out your personal information, including your name, address, and contact details.
04
Provide accurate information regarding your healthcare provider, such as their name and address.
05
Indicate the dates for which the expenses are being claimed and provide the necessary documentation.
06
Calculate the total amount of eligible medical expenses incurred during the specified period.
07
Fill out the required details regarding the type of expenses and attach any supporting documents, such as receipts or medical reports.
08
Review the completed form for any errors or omissions before submitting it.
09
Sign and date the form to certify the accuracy of the information provided.
Who needs hc 5 2017 form:
01
Individuals who have incurred medical expenses and wish to claim them for reimbursement or tax purposes.
02
Healthcare providers who need to provide information about their services for insurance or billing purposes.
03
Insurance companies or government agencies that require specific documentation for reimbursement or coverage purposes.
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What is hc 5 form?
HC 5 form is a form used to claim a refund of healthcare costs.
Who is required to file hc 5 form?
Any individual who has incurred healthcare costs and is eligible for a refund.
How to fill out hc 5 form?
The form can be filled out online or submitted by mail with relevant receipts and documentation.
What is the purpose of hc 5 form?
The purpose of the form is to claim a refund for healthcare costs incurred.
What information must be reported on hc 5 form?
The form requires details of the healthcare costs incurred, along with receipts and supporting documentation.
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