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ReimbursementAccountClaimFormMailorFaxcompletedformanddocumentationto:PayFlexSystemsUSA,Inc.
POBox8396Omaha,NE68103-8396Fax:1-855-703-5305Page1ofTohelpavoidclaimprocessingdelays,youmustsign,dateandcompletethisform.
Youmustalsoincludesupportingdocumentation.
WAIT!
DidyouknowthatyoucanfileaclaimonlineorbyusingthePayFlexMobileappLogintoyourmemberwebsiteormobileapptogetstarted.
Youcanalsofindinstructionsonlineforcompletingthisform.
MemberIdentificationNumber(EmployerassignednumberorWID)MemberFullName(LastName,First,MI)MemberAddress(Street,City,State,ZIPCode)Note:Ifyouhaveanaddresschange,pleasenotifyyouremployer.
Forsecuritypurposes,wecanonlyacceptanaddresschangefromyouremployer.
EmployerNameHealthCareExpenses(Foryou,yourspouseandyoureligibledependents)AutomaticMonthlyReimbursementforOrthodontiaexpenses:Tosetupautomaticreimbursements,checkthisbox.
Includeacopyofyourorthodontiacontractwiththisform.
Note:Forautomaticmonthlyreimbursements,youonlyneedtosendthisformandthecontractonce.
PatientNameTypeofService(deductible,dental,medical,orthodontia,overthecounter,pharmacy,vision)FromDateofService(notpaymentdate)MM/DD/YYYYTo/ThruDateofService(notpaymentdate)MM/DD/YYYYAmountRequested$$$$Total$**Ifmorelinesareneeded,pleasecompleteanotherform.
DependentCareExpenses(ChildorAdult)Ifyourcaregivercompletesandsignsbelow,youdonotneedtoincludeanitemizedstatement.
**Ifrequestingformultipledependents,eachdependentmustbelistedonaseparateline.
**ExactDatesofServiceFromMM/DD/YYYYToMM/DD/YYYYAmountRequestedQualifyingPerson's(Dependent's)FirstandLastName(PleasePrint)AgeOnServiceDateQualifyingperson(Dependent)isunderage13ORismentallyorphysicallyincapableofself-careduetoadiagnosedmedicalconditionandisoverage12.
*Pleasecheck,ifYes.
$Yes$Yes$Yes$YesTotal$*Youdonotneedtosubmitevidenceofdiagnosedmedicalcondition.
CaregiverInformation/CertificationMysignaturecertifiesthatIhaveprovidedtheservicesfortheseexpensesfor(QualifyingPerson's(Dependent's)FirstName)Name(Mustbeprinted)Relative:YesNoProviderSignatureCaregiverInformation/Certification(Note:Thisisforasecondcaregiver,ifyouhavemorethanone.
)MysignaturecertifiesthatIhaveprovidedtheservicesfortheseexpensesfor(QualifyingPerson's(Dependent's)FirstName)Name(Mustbeprinted)Relative:YesNoProviderSignatureForHealthCareFlexibleSpendingAccount:IcertifythatI,myspouseoreligibledependenthaveincurredeachexpenseonthisform.
Theseexpensesareforeligiblemedicalcare.
Theyarenotforcosmeticreasons.
Iunderstandthat"incurred"meanstheservicehasbeenprovided.
ForHealthReimbursementArrangement(HRA)members:IunderstandthatanInternalRevenueService(IRS)ruleonlyletsmeusemyHRAforeligibleindividualsifthey'recoveredbyacompliantgrouphealthplan*.
Icertifythatthepatientnotedonmyclaim(myself,spouse,oreligibledependent)iscoveredundermyEmployer'sgrouphealthplanoranothercompliantgrouphealthplan*.
Ihavereceivedandreadtheprintedmaterialregardingthereimbursementaccountsandunderstandalloftheprovisions.
*ThegrouphealthplanmustbecompliantwiththeAffordableCareAct(ACA).
Itcan'thaveannualorlifetimedollarlimitsonessentialhealthbenefits.
Anditcan'texcludecoveragebecauseofpre-existingconditions.
ForDependentCareFlexibleSpendingAccount:IcertifythatIhaveincurredtheDependentCareexpensesformeand,ifmarried,myspousetoworkorattendschool.
TheseexpensesareformyQualifyingPerson(dependent).
Thesequalifyaseligibleexpensesundermyplanandarenotforeducationalexpensestoattendkindergartenorhigher.
Iunderstandthat"incurred"meanstheservicehasbeenprovided.
ThisisregardlessofwhenIambilledorchargedfor,orpayfortheservice.
IacknowledgethatIwillhavetoreportthecaregiver'sname,addressandTaxIdentificationNumberonInternalRevenueServiceForm2441.
Ihavenotreceivedreimbursementforanyoftheseexpenses.
Iwillnotseekreimbursementelsewhere,includingfromaHealthSavingsAccount(HSA).
IfIreceivereimbursement,Iand(ifmarried)myspousewillnotclaimthesesameexpensesonourincometaxreturn.
Ihavereceivedandreadtheprintedmaterialfortheplan.
Iagreetoallofthetermsandconditionsoftheplan.
Anypersonwho,knowinglyandwithintenttodefraud,filesastatementofclaimcontaininganymaterialfalse,incompleteormisleadinginformationisguiltyofacrime.
MemberSignatureDateIfyouaremailingyourclaim,pleasekeepacopyofthisclaimformandsupportingdocumentation.
Wewillnotreturnthesedocuments.
PF-11(5-20)S