Ameriflex Details

The Flex125 Claim Form is a critical document for health insurance claims. This form allows you to provide detailed information about your medical care and treatment. By completing the form accurately, you can ensure that your claim is processed quickly and correctly. The form can be accessed on the insurer's website, or you may receive it from your provider. Be sure to complete all sections of the form and include any supporting documentation. If you have any questions, contact the insurer's customer service department.

Below is the details about the file you were in search of to complete. It can show you how much time it should take to complete flex125 claim form, exactly what parts you need to fill in, etc.

QuestionAnswer
Form NameFlex125 Claim Form
Form Length1 pages
Fillable?Yes
Fillable fields63
Avg. time to fill out12 min 55 sec
Other namesEOB, ameriflex forms, Orthodontia, flex125 com claim forms

Form Preview Example

AMERIFLEX

SPENDING ACCOUNT CLAIM FORM

Employer

Employee

Social Security #

Phone

E-mail

Medical Expense Claims (MFSA, or Employer funded HRA)

Account Type

MFSA HRA

Date Expense

Incurred

Name of Person

Receiving Medical Service

Provider Name

(Physician, Hospital, Dentist, Pharmacy, etc)

Service Provided

(Co-Pay, Deductible, Dental, Vision, RX, over-the-counter, etc)

Amount Requested

Dependent Day Care Claims

Dependent Name

Dependent

DOB

Date of Service

From To

Provider Name

Provider Tax ID #

Type of Service

(Day Care, Pre-K, Day Camp, etc)

Amount Requested

Provider Signature or Stamp

(if no receipt is available)

Commuter/Transportation Expense Claims

Expense Type

Parking Transit

Date(s) of Service

From To

Provider Name

(Transit or Parking Provider Name)

Description of Expense

(Mass Transit, Train, Van Pool, Parking, Bus, Commuter, etc)

Amount Requested

Instructions

Please read carefully and be sure your claim is completed in its entirety to ensure there is no delay in processing. Please do not use a highlighter on claim form, receipts, or any documents included as backup as this may cause a delay in processing your claim.

1)Complete all applicable sections, sign and date. Services must be incurred in order to be reimbursed.

2)Attach all required documentation (New in 2011: For an OTC medicine, please include a copy of your medical provider’s prescription or a pharmacy receipt showing the prescription #).

3)Mail, fax or email the completed claim form (scanned with signature if necessary) to AmeriFlex.

4)Please allow 2-3 weeks for paper check delivery or 7-10 days for direct deposits from the processing date.

MFSA/HRA Expenses - Acceptable forms of documentation include:

1)Explanation of Benefits (EOB): Your insurance carrier sends you an EOB each time a claim is filed. An EOB indicates your personal obligation via co-insurance or a deductible.

2)Receipts: Include name of person treated; date expense was incurred; type of service; provider name; and amount of expense. (IRS does not allow credit card receipts)

If you participate in both an MFSA and an HRA, funds will be deducted from each account based on your employer’s plan design. If you are responsible for all or a portion of the insurance deductible before employer HRA funds can be made available, you must submit an HRA Activation Form with an EOB to AmeriFlex once your portion is met as proof of the deductible status. Once approved, the employer funded HRA will be activated.

Orthodontia Expenses:

Your plan may reimburse advanced expenses for orthodontia made through a payment plan. Please contact your employer to see if these “up-front” orthodontia expenses apply. Orthodontia expenses require that both of the following be submitted with the initial claim: (1) proof of payment (e.g. provider bill indicating payments or credit card receipt); and (2) a copy of the

orthodontia contract, including amount, down payment, monthly fees and estimated length of treatment.

Dependent Day Care Expenses (Reimbursed only after service is provided) - Acceptable forms of documentation include:

Receipts including the name of the person for whom the service was provided, date expense was incurred, type of service, name of provider, amount charged and the provider’s tax ID number/SSN. If you are using a private provider (i.e. babysitter) the receipt must also include their full name, signature, address and SSN (IRS does not allow credit card receipts or statements as eligible proof of expense). If you have recurring dependent day care expenses, you can get recurring reimbursement without having to file a claim after each date of service. To set up a recurring claim, you must provide the date range of services that will be provided and a note/statement from your provider outlining the schedule of expenses for the entire period of the recurring claim. Your first expense must be substantiated after the service has been provided before you can set up a recurring claim.

Commuter/Transportation Expenses:

The IRS does not permit reimbursement for expenses older than 180 days from the date incurred.

To avoid delays in reimbursement, please sign and date this claim form and provide notice of any name or address change to AmeriFlex.

I authorize my account(s) to be reduced by the amount requested. To the best of my knowledge and belief, the statements on this form are complete and true. I am claiming reimbursement only for eligible expenses incurred by eligible plan participants during the applicable plan year. I certify that these expenses have not previously been reimbursed by this or any other benefit plan, will not be reimbursed from any other source and will not be claimed as an income tax deduction. I also understand that I may be asked to provide further details (i.e. a letter of medical necessity from a medical practitioner certifying that the expense is to treat or cure a medical condition or a more detailed certification from me). I understand that if my claim is for expenses incurred during a Grace Period: (1) the expenses will be reimbursed first from available amounts remaining at the end of the preceding Plan Year and then during the Current Plan Year; (2) claims are paid in the order in which they are approved; and (3) once paid, a claim will not be reprocessed or otherwise re-characterized so as to change the Plan Year from which funds are taken to pay it.

Employee Signature:

 

Date:

 

 

 

Mail Claim to:

AmeriFlex Claims Department

Fax Claim to:

888.631.1038

 

 

 

 

PO Box 269009

 

Attention: Claims Department

 

 

 

Plano, TX 75026

 

 

 

 

 

 

 

Email Claim to:

claims@flex125.com

 

 

 

 

 

 

AMERIFLEX

TOLL FREE: 888.868.FLEX (3539) FAX: 888.631.1038

www.flex125.com

How to Edit Flex125 Claim Form

Completing documents with our PDF editor is simpler in comparison with most things. To modify NJ the file, there is little you need to do - simply adhere to the steps listed below:

Step 1: Hit the button "Get form here" to access it.

Step 2: When you enter our NJ editing page, you will see each of the options you may undertake with regards to your document in the top menu.

Fill in the next parts to create the template:

EOB gaps to complete

Fill out the Expense Type Parking Transit, Date(s) of Service From To, (Transit or Parking Provider Name), (Mass Transit, Amount Requested, Instructions Please read carefully, e is no delay in processing, MFSA/HRA Expenses - Acceptable, and If you participate in both an MFSA areas with any information that may be requested by the software.

Expense Type Parking Transit, Date(s) of Service From To, (Transit or Parking Provider Name), (Mass Transit, Amount Requested, Instructions Please read carefully, e is no delay in processing, MFSA/HRA Expenses - Acceptable, and If you participate in both an MFSA in EOB

The application will request you to put down certain important particulars to easily complete the area To avoid delays in reimbursement, Employee Signature: Mail Claim to:, AmeriFlex Claims Department PO Box, Fax Claim to:, Attention: Claims Department, Email Claim to:, claims@flex125, Date:, and AMERIFLEX Toll Free: 888.

step 3 to finishing EOB

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