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Payflex reimbursement form

Payflex reimbursement form 2025

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The document is a claim form for reimbursement accounts from PayFlex Systems USA, Inc. It provides instructions for submitting health care and dependent care claims, including necessary documentation and eligibility criteria. The form allows users to request reimbursements for eligible expenses incurred by themselves or their dependents, with specific guidelines for covered services and required signatures.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I file for FSA reimbursement?

How do I submit a Federal Flexible Spending Account Program (FSAFEDS) online claim? You can submit your claim online by logging into My Account Summary at .FSAFEDS.com , clicking on My Claims, and selecting Online Claim Submission. You must upload an image of your supporting documentation in .

Do I need to claim my FSA on my taxes?

Please save your receipts and other supporting documentation related to your HC FSA expenses and claims. The IRS may request itemized receipts to verify the eligibility of your expenses. Credit card receipts, canceled checks, and balance forward statements do not meet the requirements for acceptable documentation.

How do I submit documentation to PayFlex?

Go to payflex.com and click Documents Forms at the top of the page. Select Administrative Forms and click Flexible Spending Account Claim Form. Complete all fields of the form. Sign and date the form. Mail or fax your completed claim form and supporting documentation to PayFlex.

How do I get my money from FSA?

If I participated in a Health Care FSA, do I need to report anything on my personal income tax return at the end of the year? No. There are no reporting requirements for Health Care FSAs on your income tax return.

How do I get reimbursed from PayFlex?

Log in to pebc.payflex.com and under Account Actions select File a claim. Then complete the required fields to quickly file your claim. Paper Claim Filing: If you prefer to file your claim manually, follow these steps. Claim forms are available on pebc.payflex.com.

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How to submit for FSA reimbursement?

Typically, there are three ways to access your FSA money. You can use a debit card thats connected to your account, pay providers directly through your online portal, or submit receipts for reimbursement. Check with your employer or FSA provider to find out which option(s) they offer.