Fillable Flexible Spending Accounts Claim Form printable pdf download

Clear Form

MAIL TO:

FAX TO:

PayFlex Systems USA, Inc.

Health/Dependent Care

P.O. Box 3039

(402) 231-4310

Flexible Spending Accounts

Omaha, NE 68103-3039

(No Cover Page Required)

Claim Form

(402) 345-0666

Page 1 of ______

WAIT! Did you know that you can file this claim online? Go to

and select Express Claims.

You can access your account balance, view a listing of eligible expenses and frequently asked questions all in one place!

Employee Name _____________________________________ Member Number ____________________________

(This may be your SSN or employer assigned number)

Employer Name _________________________________________________________________________________

Note: To make an address change, please contact your employer’s HR/Benefits department. For security purposes, we cannot accept address changes directly.

Health Care Claims

(For you or your dependents)

- For additional information, please visit our website at: .

Covered by insurance - Expenses for services or items must be submitted to your insurance company before submitting for reimbursement under your flexible spending account.

When you receive the Explanation of Benefits Statement (EOB) from your insurance company, include a copy with this completed claim form. If you have a copay, attach

an itemized statement from your service provider. Do not submit expenses previously paid for with your PayFlex Debit Card.

Not covered by insurance - For services or items, submit an itemized statement from the provider showing the provider’s name and address, patient name, date the service was

provided, a description of the service, and the amount charged along with this completed claim form. Balance forward statements, cancelled checks, credit card receipts or

received-on-account statements are not acceptable. Orthodontia claims require an itemized statement/payment receipt, the orthodontist’s contract/payment agreement or

monthly payment coupons.

Prescription and over-the-counter drugs and medicines require a print-out of prescriptions from your pharmacy or must be clearly identifiable on an itemized receipt. Quantities

purchased must be reasonably able to be consumed during the current plan year. Items for maintaining general good health, cosmetic purposes and dietary supplements are not

eligible.

Type of Service (Ex. – Prescription,

Date of

Amount

Over-the-Counter, Vision, Dental,

Service

Requested

Hearing, Office Visit, etc…)

Total

0.00

Dependent Child or Adult Day Care Claims

- For additional information, please visit our website at: .

Complete this form and attach an itemized statement from your day care provider or have your provider complete the information below. IRS regulations allow payment of

services for dependents under age 13 or otherwise satisfying the “Qualifying Person Test” as described in IRS Publication 503. Payment is only allowed for services that

have already been provided, not for services to be provided in the future. You are required to report the provider’s name, address and Tax Identification Number or Social

Security Number on Form 2441 with your personal income tax return. If your day care provider completes and signs this form below, no other itemized statement is necessary.

Amount

Exact Dates of Service

Dependent Name

Requested

From

otal

0.00

Day Care Provider Information:

Name _______________________________________________

Provider

Signature_____________________________________________

Signature____________________________________________

I certify that these eligible expenses have been incurred by me, my spouse or eligible dependent and medical expenses are not for cosmetic purposes but for the treatment of an

illness, injury, trauma, or medical condition. I understand that “incurred” means the service has been provided that gave rise to the expense, regardless of when I am billed or

charged for, or pay for the service. The expenses have not been reimbursed and I will not seek reimbursement elsewhere. I understand that any amounts reimbursed may not be

claimed on my or my spouse’s income tax returns. I have received and read the printed material regarding the reimbursement accounts and understand all of the provisions.

Employee Signature

Date

____________________________________________________

___________________

***Make copies for yourself, since these documents will not be returned. If you fax your claim, keep the original.***

Rev. 2/2008