Payflex claim form 2026

1. Click ‘Get Form’ to open the payflex claim 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, please contact your employer’s HR/Benefits department directly.
4. For Health Care Claims, indicate whether the expenses are covered by insurance. Attach the Explanation of Benefits (EOB) from your insurance company along with any itemized statements for copays or non-covered services.
5. For Dependent Child or Adult Day Care Claims, provide exact dates of service and attach an itemized statement from your day care provider. Ensure that all required information is filled out accurately.
6. Finally, sign and date the form at the bottom to certify that all information is correct and that you will not seek reimbursement elsewhere.

Start filling out your payflex claim form online for free today!