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Click ‘Get Form’ to open the payflex form in the editor.
Begin by entering your Member Identification Number and Full Name in the designated fields. Ensure that you provide your complete address, as any changes must be communicated through your employer.
In the Health Care Expenses section, indicate if you or your dependents have coverage under another plan by selecting 'Yes' or 'No'. If applicable, attach a copy of the Explanation of Benefits (EOB) for each service date.
For automatic monthly reimbursements for orthodontia expenses, check the appropriate box and include a copy of your orthodontia contract.
Fill in the details for each health care service provided, including Patient Name, Type of Service, Dates of Service, and Amount Requested. If more lines are needed, simply complete another form.
In the Dependent Care Expenses section, list each dependent on a separate line along with their service dates and amounts requested. Ensure that caregiver information is filled out accurately.
Finally, review all entries for accuracy before signing and dating the form at the bottom. Remember to keep a copy of this claim form and supporting documentation if mailing it.
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You may use your PayFlex Card at most retail or online locations to pay for prescriptions and certain OTC items. Such OTC items include bandages, contact lens solution, first aid kits, hot and cold packs, and thermometers.
Can I withdraw cash from Payflex to my bank account?
If you linked a bank account (set up direct deposit), you can choose Send funds to my bank account.
What items can I buy with my PayFlex card?
Through HealthHubs Consumer Center, you can buy items such as glasses, contacts, prescription drugs, durable medical equipment and certain over-the-counter items using your PayFlex Card. If an item is not identified as FSA eligible you will need to use a form of payment other than your PayFlex Card.
How do I get my 1099-SA form from PayFlex?
1099-SA Well mail this to you in January. It shows your HSA withdrawals during the calendar year. Youll use this information to complete IRS Form 8889 when you file your federal tax return. A copy will be sent to the IRS on your behalf.
Is Payflex a debit or credit card?
The PayFlex Card makes it easy for you to spend the money in your tax-advantaged account. When you use this debit card, it uses the money in your account to pay for eligible health care expenses. Check with your employer to find out if you can have a PayFlex Card and what expenses are eligible under your plan.
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Theres no detailed application process. To apply, simply select Payflex as your payment method at checkout, provide your ID number, and well assess you in seconds. The system works in real time. Meaning, if everything checks out, youll be good to shop in less than a minute.
Does Payflex require credit score?
To apply for your Payflex account, simply select Payflex as your payment method at checkout, provide your ID number, and well assess you in seconds. No documentation required, but there are qualifying criteria that includes having a good credit rating and credit history.
How do I file a claim with 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.
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PayFlex - Reimbursement Account Claim Form
To help avoid claim processing delays, you must sign, date and complete this form. You must also include supporting documentation.
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