Form Pf-11 - Payflex Reimbursement Account Claim Form

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Reimbursement Account

Mail or Fax completed form and documentation to:

PayFlex Systems USA, Inc.

Claim Form

PO Box 981158

El Paso, TX 79998-1158

Fax: 1-855-703-5305

Page 1 of

To help avoid claim processing delays, you must sign, date and complete this form. You must also include supporting documentation.

WAIT! Did you know that you can file a claim online or by using the PayFlex Mobile

app?

Log in to your member website or mobile app to get started. You can also find instructions online for completing this form.

Member Identification Number (Employer assigned number or W ID)

Member Full Name (Last Name, First, MI)

Member Address (Street, City, State, ZIP Code)

Note: If you have an address change, please notify your employer. For security purposes, we can only accept an address change from your employer.

Employer Name

Health Care Expenses

(For you, your spouse and your eligible dependents)

Automatic Monthly Reimbursement for Orthodontia expenses: To set up automatic reimbursements, check this box. Include a copy of your

orthodontia contract with this form. Note: For automatic monthly reimbursements, you only need to send this form and the contract once.

Type of Service

From Date of Service

To/Thru Date of Service

(deductible, dental, medical,

(not payment date)

orthodontia, over the counter,

Patient Name

pharmacy, vision)

MM/DD/YYYY

Amount Requested

Total $

**If more lines are needed, please complete another form.

Dependent Care Expenses (Child or Adult)

If your caregiver completes and signs below, you do not need to include an itemized statement.

**If requesting for multiple dependents, each dependent must be listed on a separate line.**

Qualifying person (Dependent) is under

Exact Dates of Service

age 13 OR is mentally or physically

Qualifying Person’s (Dependent’s)

incapable of self-care due to a diagnosed

Age

From

First and Last Name

medical condition and is over age 12.

On Service

MM/DD/YYYY

Amount Requested

(Please Print)

Date

*Please check, if Yes.

Yes

Total

*You do not need to submit evidence of diagnosed medical condition.

Caregiver Information/Certification

(Note: This is for a second caregiver, if you have more than one.)

My signature certifies that I have provided the services for these expenses

for

(Qualifying Person’s (Dependent’s) First Name)

Name (Must be printed)

Relative:

Yes

Relative:

Yes

Provider Signature

For Health Care Flexible Spending Account: I certify that I, my spouse or eligible dependent have incurred each expense on this form. These expenses are for eligible medical care. They

are not for cosmetic reasons. I understand that “incurred” means the service has been provided.

For Dependent Care Flexible Spending Account: I certify that I have incurred the Dependent Care expenses for me and, if married, my spouse to work or attend school. These expenses

are for my Qualifying Person (dependent). These qualify as eligible expenses under my plan and are not for educational expenses to attend kindergarten or higher. I understand that “incurred”

means the service has been provided. This is regardless of when I am billed or charged for, or pay for the service. I acknowledge that I will have to report the caregiver’s name, address and

Tax Identification Number on Internal Revenue Service Form 2441.

I have not received reimbursement for any of these expenses. I will not seek reimbursement elsewhere, including from a Health Savings Account (HSA). If I receive reimbursement, I and (if

married) my spouse will not claim these same expenses on our income tax return. I have received and read the printed material for the plan. I agree to all of the terms and conditions of the

plan. Any person who, knowingly and with intent to defraud, files a statement of claim containing any material false, incomplete or misleading information is guilty of a crime.

Member Signature

Date



If you are mailing your claim, please keep a copy of this claim form and supporting documentation. We will not return these documents.

PF-11 (9-15) HH