WageWorks' easy-to-use-and-understand claim forms enable you to submit claims by mail or fax, and get reimbursed quickly. Click on the appropriate claim form you require and it will open up in any web browser. Just print it out, mail or fax it in, along with the appropriate receipts, and you're done!

WageWorks is pleased to introduce a revised Pay Me Back claim form design.  The Health Care and Dependent Care Pay Me Back claim forms have been re-designed with you in mind! 

• The layout of the claim form has been changed to be more user friendly
  
  
• The instruction page has been revised and now provides you with a sample
  of a completed form
  
  

Health Care Claim Form   |  Documentation Checklist Dependent Care Claim Form Commuter Claim Form

To view and print the forms, you need the Adobe Acrobat Reader installed on your computer. Adobe Acrobat Reader is free and can be run as an independent program or as a "plug-in" for most major web browsers to allow online viewing of PDF documents.

To download the Reader click on the "Get Adobe Reader" link below. This will take you to Adobe Systems' website. Follow the detailed instructions on the Adobe website to download and then install the software on your computer.