Payflex Claim Form PDF Details

The Payflex Claim Form serves a crucial role for individuals using Flexible Spending Accounts (FSAs) for both healthcare and dependent care expenses, streamlining the reimbursement process for various eligible expenses. As directed by PayFlex Systems USA, Inc., this form must be filled out meticulously and accompanied by requisite supporting documentation to ensure a smooth claim process, with options for submission via mail or fax. A noteworthy feature is the convenience offered to users preferring digital means, with an online claim filing option available through the PayFlexDirect website or Aetna Navigator, highlighting the adaptability of the system to modern user preferences. The form requires detailed information regarding the claimant and the nature of the expenses, including dates of service, amounts requested, and specific details about the healthcare or dependent care provided. An intriguing aspect for those with orthodontia expenses is the option for setting up automatic reimbursements, demonstrating PayFlex's commitment to customer convenience. Furthermore, it emphasizes compliance with regulations governing FSA reimbursements, including certifications by the claimant regarding the eligibility of the expenses and acknowledgments concerning the non-duplication of reimbursements. This comprehensive approach not only facilitates efficient processing but also underscores the importance of integrity and accountability in managing FSA funds.

QuestionAnswer
Form NamePayflex Claim Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesPayFlexDirect, payflex claim form 2019, payflex flexible spending account claim form, payflex claim form

Form Preview Example

Flexible Spending Account

Claim Form

Health Care & Dependent Care

Mail or Fax completed form and documentation to: PayFlex Systems USA, Inc.

P.O. Box 4000

Richmond, KY 40476-4000 Fax: (888) 238-3539 Page 1 of ______

For the hearing impaired, call 1-877-703-5572

To avoid claim payment delay, you must sign, date and complete this form. You must also include supporting documentation.

WAIT! Did you know that you can file a claim online? Log in to www.PayFlexDirect.com or accessible via Aetna Navigator, select File a Claim under

Quick Links. You can also find instructions online for completing this form.

Member Identification Number:

(Employer assigned number or W ID)

Member Full Name:

(Last Name, First, MI)

Member Address:

(Street, City, State, Zip Code)

Note: If you have an address change, please notify your employer. For security purposes, we can only accept an address change from your employer.

Employer Name:

Health Care Expenses (For you, your spouse and your dependents)

Coordination of Benefits: Do you, your spouse or dependent have coverage under another plan? This includes any medical, dental, prescription or vision plan

other than your primary coverage?

Yes – you must include a copy of the EOB for each date of service

No

Automatic Monthly Reimbursement for Orthodontia expenses: To set up automatic reimbursements, check this box. Include a copy of your orthodontia contract with this form. Note: For automatic monthly reimbursements, you only need to send this form and the contract once.

Patient Name

Type of Service

From Date of Service

To/Thru Date of

Amount Requested

 

(deductible, dental, medical,

(not payment date)

Service

 

 

orthodontia, OTC, RX, vision)

MM/DD/YYYY

(not payment date)

 

 

 

 

MM/DD/YYYY

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

**If more lines are needed, please complete another form. You can get claim forms at www.PayFlexDirect.com or accessible

 

 

via Aetna Navigator under MyPayFlexDirect Resources and select Administrative Forms. Attach the appropriate documentation

Total

$

for each claim.

 

 

 

 

 

 

 

 

 

Dependent Care Expenses (Child or Adult) - If your caregiver completes and signs below, you do not need to include an itemized statement.

**If requesting for multiple dependents, each dependent must be listed on a separate line.**

Exact Dates of Service

Amount

Qualifying Person’s

 

 

 

Qualifying person is under age 13

 

 

 

 

 

 

Age

OR is mentally or physically

 

 

 

 

 

From

 

To

Requested

First and Last Name

 

 

On Service Date

incapable of self-care due to a

MM/DD/YYYY

MM/DD/YYYY

(Required)

 

(Please Print)

 

 

(Required)

diagnosed medical condition and is

 

 

 

 

 

 

 

 

 

 

 

over age 12.**Please check, if yes.

 

 

 

 

$

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

Total

 

$

**You do not need to submit evidence of diagnosed medical condition.

 

 

 

 

 

 

Caregiver Information/Certification: My signature certifies that I have provided the

 

Caregiver Information/Certification: My signature certifies that I have provided the

services for these expenses for ___________________(Qualifying Person’s First Name)

 

services for these expenses for __________________(Qualifying Person’s First Name).

Name (Must be printed)___________________________________________

 

Note: This is for a second caregiver, if you have more than one.

 

Name (Must be printed)_____________________________________________

 

 

 

 

 

 

 

Relative:

Yes

No

 

 

 

Relative:

Yes

No

 

 

 

 

 

 

 

 

 

Provider Signature _____________________________________________

 

Provider Signature _____________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Health Care FSA: I certify that I, my spouse or eligible dependent have incurred each expense on this form. These expenses are for eligible medical care. They are not for cosmetic reasons. I understand that “incurred” means the service has been provided.

For Dependent Care FSA: I certify that I have incurred the Dependent Care expenses for me and, if married, my spouse to work. These expenses are for my Qualifying Person. These qualify as eligible expenses under my plan and are not for educational expenses to attend kindergarten or higher. I understand that “incurred” means the service has been provided. These are regardless of when I am billed or charged for, or pay for the service. I acknowledge that I will have to report the caregiver’s name, address and Tax Identification Number on Form 2441.

I have not received reimbursement for any of these expenses. I will not seek reimbursement elsewhere, including from a Health Savings Account (HSA). If I receive reimbursement, I and (if married) my spouse will not claim these same expenses on our income tax return. I have received and read the printed material for the FSA or Limited FSA plan. I agree to all of the terms and conditions of the plan. Any person who, knowingly and with intent to defraud, files a statement of claim containing any material false, incomplete or misleading information is guilty of a crime.

Employee Signature__________________________________________________

Date __________________

**If you are mailing your claim, please keep a copy of this claim form and supporting documentation. We will not return these documents.** REV. 08/2012

69.09.300.1 (10/12)

© PayFlex Systems USA, Inc.

How to Edit Payflex Claim Form Online for Free

In case you want to fill out Orthodontia, you don't have to download any sort of software - just try using our PDF tool. In order to make our tool better and easier to use, we constantly work on new features, considering suggestions coming from our users. To get started on your journey, consider these simple steps:

Step 1: Access the PDF form inside our tool by clicking on the "Get Form Button" above on this page.

Step 2: The editor helps you customize PDF files in a variety of ways. Modify it by writing your own text, adjust existing content, and add a signature - all within the reach of several mouse clicks!

This document will require specific details to be filled in, hence make sure you take whatever time to fill in precisely what is asked:

1. It is very important complete the Orthodontia accurately, therefore be attentive while filling in the parts comprising all of these fields:

Completing section 1 in FSA

2. Right after completing the previous step, head on to the subsequent step and fill out the essential particulars in these blanks - If more lines are needed please, Total, Dependent Care Expenses Child or, If requesting for multiple, Exact Dates of Service, From, MMDDYYYY, MMDDYYYY, Amount, Requested, Required, Qualifying Persons First and Last, Please Print, Age On Service Date, and Required.

Filling out section 2 of FSA

3. The following section focuses on I have not received reimbursement, Employee Signature Date, If you are mailing your claim, and PayFlex Systems USA Inc - fill in all of these fields.

PayFlex Systems USA Inc, If you are mailing your claim, and I have not received reimbursement in FSA

As for PayFlex Systems USA Inc and If you are mailing your claim, be sure you get them right in this current part. Both of these are the most important ones in this document.

Step 3: Check all the details you've entered into the form fields and then hit the "Done" button. Right after setting up afree trial account with us, it will be possible to download Orthodontia or email it immediately. The PDF file will also be accessible via your personal account menu with all your edits. FormsPal is committed to the confidentiality of our users; we make sure that all personal data handled by our system is protected.