Payflex reimbursement form 2026

1. Click ‘Get Form’ to open the payflex reimbursement form in the editor.
2. Begin by entering your Employee Name and Member Number at the top of the form. This may be your Social Security Number or an employer-assigned number.
3. Fill in your Employer Name. If you need to change your address, contact your HR/Benefits department directly.
4. For Health Care Claims, indicate whether expenses are covered by insurance. Attach the Explanation of Benefits (EOB) from your insurance company along with any itemized statements as required.
5. Complete the sections for each service provided, including Date of Service, Type of Service, and Amount Requested. Ensure all details are accurate and clear.
6. For Dependent Child or Adult Day Care Claims, provide exact dates of service and have your provider sign below or attach an itemized statement.
7. Finally, certify that all information is correct by signing and dating the form before submission.

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