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 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）

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。