Payflex claim form 2025

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The document is a claim form for Health and Dependent Care Flexible Spending Accounts provided by PayFlex Systems USA, Inc. It outlines the process for submitting claims for reimbursement of eligible medical expenses and dependent care costs, including necessary documentation and eligibility criteria. The form also includes instructions for online claim filing and emphasizes the importance of itemized statements from service providers.

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Versions	Form popularity	Fillable & printable
2010	4.8 Satisfied (48 Votes)
2010	4 Satisfied (30 Votes)

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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 does Payflex payment work?

Heres how it works: When checking out the customer completes a quick form and is instantly vetted. Upon approval, they then pay the first 25% of their purchase (R500) as a deposit, using their credit or debit card. Payflex then collects the other 75% in three instalments of R500 each over the next six weeks.

How are FSA reimbursements paid?

After the claim and supporting documentation have been reviewed and the expense approved, payment is issued to you via direct deposit (for fastest processing) or check.

How do I submit a claim 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 does PayFlex reimbursement work?

Generally, when you use your PayFlex Card or submit a claim to us, approved expenses will be paid from your health care FSA first. Once youve spent all the funds in your FSA, your HRA will pay your eligible expenses.

What happens to unused Payflex funds?

Generally, funds left in an FSA at the end of the year are forfeited. This is the FSA use-it-or-lose-it rule. However, your plan may have a grace period or carryover feature, which can help reduce forfeitures.

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.

How do I file an FSA claim?

Its easy to print out a paper claim form online. Log in to payflex.com and select the Resource Center tab. Mail: PayFlex, P.O. Box 4000, Richmond KY 40476-4000. Note: Dont forget to include supporting documentation with your claim.

Payflex claim form 2025

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