Primepay Form Claim PDF Details

When dealing with healthcare expenses, the Primepay Claim Form, specifically designed as a Health Reimbursement Arrangement (HRA) Claim Form, emerges as a critical document for employees seeking reimbursement for eligible medical expenses. This form allows employees to meticulously list their expenses that are set to be reimbursed, thus highlighting the necessity of attaching supportive documents such as copies of Explanation of Benefits (EOBs) or receipts. Key sections of the form request detailed employee information, including address, social security number, employer details, and contact information, ensuring that the claim is accurately associated with the right individual. Particularly noteworthy is the provision allowing employees to opt for direct payment to their medical providers, a feature that underscores the form’s flexibility in managing reimbursements. Moreover, the form emphasizes the importance of attesting to the exclusivity of the claim to the plan in question, ensuring that the expenses have not been, and will not be, compensated through any other health plan or insurance. This declaration is crucial for maintaining the integrity and legal standing of the claim. Through its structured format, the form also guides the claimant in assuring that the expenses listed are only those eligible for reimbursement under the plan, thereby aligning with IRS guidelines specifying that the incurred date of service is what determines eligibility—not necessarily the payment date. With its comprehensive approach, the Primepay Claim Form serves as a vital tool for employees to navigate the reimbursement process efficiently, while also fulfilling all necessary legal and regulatory requirements for claiming health-related expenses.

QuestionAnswer
Form NamePrimepay Form Claim
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprimeflex medical health, form 20 reimbursement, primeflex claim, primepay reimbursement

Form Preview Example

Eligible Expenses To Be Reimbursed -

Office Use Only

Date Processed:

/

/

 

 

 

Processed by:

 

Client # :

PrimeFlex: Form # 20 –

Health Reimbursement Arrangement Claim Form

PLEASE COMPLETE THIS FORM AND FAX IT – ALONG WITH COPIES OF YOUR EOB AND/OR RECEIPTS – TO PRIMEFLEX AT 877-6FAX-HRA.

To be completed by employee

Employee Information (Please print clearly)

PLEASE CHECK HERE IF THIS IS AN ADDRESS CHANGE

Name: (Last, First, Middle)

 

Social Security Number:

 

Date of Birth:

 

 

 

 

 

 

Street:

City:

State:

 

Zip Code:

 

 

 

 

 

Employer:

 

 

Work Telephone Number:

 

 

 

 

 

E-mail:

 

 

Home Telephone Number:

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE ISSUE PAYMENT DIRECTLY TO THE MEDICAL PROVIDER(S) OF SERVICE LISTED BELOW. I CONFIRM THAT I HAVE COMPLETED & ATTACHED THE PROVIDER PAY FORM OR INCLUDED THE MEDICAL INVOICE FOR EACH PROVIDER REQUIRING DIRECT PAYMENT FROM PRIMEFLEX.

Please list only expenses that are eligible for this plan. Attach copies of receipts and/or EOBs (on a separate piece of paper) supporting each expense item listed below.

Description of Expense

Family Member

Date Incurred

Amount of Claim

Total amount this claim $

READ CAREFULLY!

The undersigned participant in the plan certifies that all expenses, for which reimbursement or payment is claimed by submission of this form, were incurred while the undersigned was covered under the Plan with respect to such expenses. IRS regards the date incurred as being when the service is rendered, not when you actually pay the bill. The undersigned participant also certifies that amounts claimed are not eligible for payment under any other health care plan or program, federal, state or governmental program, workers’ compensation, or any other policy of health insurance. The undersigned fully understands that he or she alone is fully responsible for the sufficiency, accuracy and validity of all information relating to this claim which is provided by the undersigned. The undersigned further understands that no medical expense tax deduction is permitted for amounts for which reimbursement is made.

Employee Signature: __________________________________________________ Date: ______/______/______

Retain the original receipts and a copy of this form for your records. For Tax Purposes – Use only for expenses incurred in the same plan year for yourself or members of your family who are dependents.

PrimeFlex: HRA Claims – 1487 Dunwoody Drive, West Chester, PA 19380 | 877.769.3539 | primeflexhra@primepay.com

How to Edit Primepay Form Claim Online for Free

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Step 1: Access the PDF doc in our tool by clicking the "Get Form Button" in the top part of this page.

Step 2: As you open the editor, you will notice the document all set to be filled in. Besides filling in various blanks, it's also possible to perform other actions with the file, namely putting on any text, editing the initial text, adding images, signing the form, and a lot more.

This form will require particular info to be entered, thus make sure to take your time to type in what's required:

1. It is important to fill out the primeflex claim properly, thus take care while filling out the areas that contain all these fields:

primepay reimbursement completion process explained (part 1)

2. Once your current task is complete, take the next step – fill out all of these fields - READ CAREFULLY, Amount of Claim, Total amount this claim, and The undersigned participant in the with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Tips on how to complete primepay reimbursement stage 2

Many people generally make some errors when filling out Amount of Claim in this part. Make sure you read again everything you type in right here.

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