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? If this is a ? If new resubmission address MEDICAL EXPENSE REIMBURSEMENT ACCOUNT CLAIM FORM Use this form for eligible expenses incurred by you or your eligible dependents. SECTION A Account Holder

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4. Follow any instructions provided on the form or document you are completing. This may include providing specific details, checking boxes, or signing in designated areas.
5. Double-check your completed form for accuracy and make any necessary corrections before faxing.
6. Attach the completed form to a clean and legible fax cover sheet.
7. Dial the appropriate fax number and follow the instructions on your fax machine to send the completed form.

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