You will continue to receive communications that are necessary for providing our services. We will maintain the confidentiality of your personal information in accordance with our privacy policy. Follow these easy steps: 1. Upon receipt of the form, an investigator will review the documents. Info@FlexFacts.com FSA Spending Account Claim Form … �1.s��-��~���b��>'r��˜�y7�������_Q�GԄ}�E��A�Àȫ2$W���w� Tired of looking for receipts, claim forms … Personal Information . Click here to download Adobe PDF Reader. Before you can access your account, you must register with the site and create a username and password.Test To do so, click ‘Manage’ or ‘Opt-out’ on one of the marketing emails you received or click the Opt-out link below and complete the form request. Or, you can snap a picture of your documentation and submit via the ASIFlex mobile … Let us help. 1200 River Ave, Suite 10E, Lakewood, NJ 08701, www.FlexFacts.com, 877-94-FACTS (32287) HRA Claim Form Personal Information Full Name: Last First M.I. %PDF-1.7 An HRA is a reimbursement account set up and funded by your employer to cover eligible healthcare expenses. Customers (Individuals, Employees & Their Families) We make it easier to access your account information. ©ConnectYourCare Form 400001 (10/2014) Flexible Spending Account Enrollment Form . stream Flex Facts, 1200 River Ave, Suite 5C, Lakewood, NJ 08701, www.flexfacts.com, 877-94-FACTS (32287) Spending Account Claim Form Personal Information 2ЌDìur¸{ÃHI@ UVÐ攔u¤s˜×Â)IÇwªäÍ1›˜¾eûÖ©ñh¸‡-¶#|ˆEñn…‘“? ÜXÐc€®(=Xù P׀ªTõq¨ÐŒ§ð3lC‚&¦ ßó¯ï0¾½ßÝàx¾Úpéíͼ¶[žÑÅpô58ü ‚u,sã5ü) Note: Paperless claim submission is only available to PPO participants. }8[©² ‚ÿuVRQìR&Ò= GHU2Gq™Lõ?ôŠɃ1õb’£ôduUÖÒÁ"¡ASŠŠƒ¢CD£š²ürœª\6¥h»°¡%£)M냦$£Šò†•*dbS\@apbÀœñ¦ô\3%itgEㅃÆ5)à0®ú‰(ŠãäӃùPé FIELD OFFICE. Employer: Last Four Digits of Your Social Security Number Phone: ( ) E-mail: If your address has changed please list the new address below. 8700 W. Bryn Mawr Avenue, Suite 1010S, Chicago, IL 60631 Phone: 847-699-6900 Fax: 847-699-6906. • To file electronically, log into your FlexFacts FSA account and follow the instructions. Dependent Care Reimbursement Plan Guidelines Employer provided dependent care assistance is tax-free only if the … 2 0 obj Claim Forms Aetna Medical Claim Form Aetna Vision Claim Form / Instructions Dental Claim Form BeneCardPBF Claim Form FlexFacts Claim Form Enrollment Forms Printable SHIF Enrollment Form. ��1!cE�P��rJ�L�iG!���SbQ� Don’t have an account? Manual claims are reimbursed via direct … • To file via fax or mail, complete a Claim Form and send with a copy of the EOB/receipt to: FlexFacts Claims Department, 7 Grant Avenue, Lakewood, NJ 08701 or fax to 877-747-8564. FSA Change of Status Form Employers FSA Guide HRA Direct Deposit Form HSA Change of Status Form Premium and HSA Contributions Form Premium, HSA and Limited FSA Form POP The POP Info Sheet endobj þß# ìçŤ }@ÍÂæn@­Í&:¢ñÍ=%Õי»§ð›ÍÝ=ңߏm ç*Õ¸J¢}”ïd ɨºÎÉ. áéø¦o žƒñ¢ œÌC•5èÂÁJPúË_¬à™‚¦kªÄšª¨ËÅ8#ò#Ô â€¢ To file electronically, log into your FlexFacts FSA account and follow the instructions. Email: Email your completed Claim Form and receipts to claims@flexfacts.com Mail/ Fax: Complete a Claim Form and send it along with a copy of the receipt/invoice to: Flex Facts Claims Department 1200 River Ave, Suite 10E Lakewood, NJ 08701 Fax: 877 … However, you may submit a claim every week, at the end of that week, for those expenses. Opt-out You must also include supporting documentation. Flexible Spending Accounts Forms to initiate pre-tax payroll deductions for unreimbursed medical and dependent care expenses are available from the third party administrator, FLEXFACTS. Complete all entries on this Enrollment Form. Account” tab and click “Submit Claim” and follow the Online instructions. Forgot your Username? Sign in. Details: your health reimbursement arrangement ©2015 FlexFacts 1200 River Ave, Suite 10E Lakewood , NJ 08701 877-943-2287 www.FlexFacts.com How are HRAs and FSAs different? To be reimbursed for over-the-counter medications, you must submit your claim with a prescription … Contribution Grid for Spouses Qualifying HSA … New User? 3. New Address: City, State, Zip Claim … Fillable PDF SHIF Enrollment Form BeneCardPBF Enrollment Form But for most of us, cellphones are also inextricably linked to our personal lives, so it’s a deduction that the IRS scrutinizes very carefully to make sure personal electronics use isn’t being … Adjusted claims are not processed through CrossTech and need to be submitted manually. �n¨J bh�n��� A���O��z�0!&��P��JE���)�_�6��HrB��B���L�h�U�3�+�&$baF��c�c�N7��j�(Jslބn�X����4=菓�h�0%Ls���l3'lv� �m���z.q�W�s�>���8/s$�W�hK ��tU��?^f��g�T���>+�)Ӯ��1�L4�~���#0��t�zpR�e. Flex Facts, 7 Grant Ave, Lakewood, NJ 08701, www.flexfacts.com, 877-94-FACTS (32287) Flexible Spending Account Claim Form Personal Information Full Name: Last First M.I. Due to the time it takes to gather all the documents relevant to your claim, it may take up to 90 days to … To protect your personal information, we collect your password on a separate page. Before you submit a claim, review page 1 of the claim form, “How to Submit Claims.” You can also submit claims online by clicking the Online Access/Account Detail tab above and then selecting Participant/Account Detail. Please print. ... • To file via fax or mail complete a Claim Form and send it along with a copy of the receipt/invoice to: • Flex Facts Claims Department, 1200 River Ave, Suite 5C, Lakewood, NJ 08701, Forms: Flex Facts Flex Facts a company of grant benefit solutions which administers Medical & Dependent Care Flexible Spending Accounts, Commuter Benefits and Healthcare Reimbursement Arrangements on a single debit card platform. • Go to: flexfacts.com • At the bottom of the page, click on FSA Eligible Expense Table What about over-the-counter medications? 877-943-2287. Find the most frequently used carrier forms you need right here - just click and print! … For example, if you are required to pay for all of January's child care expenses on January 1st, you cannot claim the entire month's expense until the end of January. Attached is the CrossTech election form and if you have questions, please feel free to call your Flex representative at (866) 472-0882. B�lV�aO�L���?�̖Op���ω�0�V��h�nJ �s�W��*s!C@_�Y_V�r�v9!.���%�"�C#;�ja�f_��?O�y�� Submit it to your Human Resources Department. Last Four Digits of Your Social Security Number Phone. 1 0 obj Last Employer. Employee Name (last name, first name) Social … a��Sʦ9c! Deductions are authorized on a yearly basis during the open enrollment period. Click here to establish your username and password to manage your account. FlexFacts. Cellphones have become just as vital to business as a land line, which makes cellphone use a legitimate, deductible business expense. Employer: Social Security Number Phone: ( ) E-mail: If your address has changed please list the new address below. WAIT! New Address: City, State, … Flex Facts, 1200 River Avenue, Suite 5C, Lakewood, NJ 08701, www.flexfacts.com Toll Free: 877-94-FACTS (32287), Local: 732-640-5951 Filing a Claim Did you know that you can file a claim … Please send the completed claim form and detailed bills/ EOBs to: Email: claims@flexfacts.com Fax: 877-747-8564 Mail: 1200 River Avenue, Suite 10E, Lakewood, NJ 08701 Medical & Dependent Care Claim Form 4 0 obj To prove the validity of the claim, the claimant may include a letter, a receipt, an original photograph, and all those physical entities that have to do with … 1200 River Ave, Suite 10E Lakewood, NJ 08701 www.FlexFacts.com. Mail or Fax completed form and documentation to: PayFlex Systems USA, Inc. PO Box 8396 Omaha, NE 68103-8396 Fax: 1-855-703-5305 Page 1 of . x��]mo�8���@�}�E|�� �$=Y�`�ѷ���nn?�'1Ʊ3�3=�﯊/�$��,+ N,��Yŧ�E��?�V���]��O�����~y��zz�����9���qy�yq��,v�����˷^��nw˧�����e���7E^��"4+�^��������[�y�����7�W$#$/x�������$�4+y.�(��/2�{�:�;�������ͯ�������}�3��_o�]�7�5�Z��l��h͋2�v�����n~�g��a�B� Flex Facts, 1200 River Avenue, Suite 5C, Lakewood, NJ 08701, www.flexfacts.com Toll Free: 877-94-FACTS (32287), Local: 732-640-5951 If you are not able to use your card at the point of service you can file a claim online, by fax or by mail. The form should have supporting documents as proof, and it should be held by an attorney to face the court sessions. All forms are in PDF format. You can also opt out of marketing communications. Through this site, you can manage your benefit accounts all in one place, view transaction history, submit claims online, view your communication history and take advantage of other services. info@flexfacts.com. The Dependent Care deduction should be shown in box 10 of the W2 form from your employer. 2. endobj • To file via fax or mail, complete a Claim Form and send with a copy of the EOB/receipt to: FlexFacts Claims Department, 7 Grant Avenue, Lakewood, NJ 08701 or fax to 877-747-8564. To help avoid claim processing delays, you must sign, date and complete this form. Spending Account Claim Form Full Name. Contact Us. FLEX BENEFIT ADMINISTRATORS www.fbaflex.com claims@fbaflex.com PO BOX 800518 HOUSTON, TX 77280-0518 PHONE (713) 460-FLEX (3539) FAX (713) 460-3550 Claim for Reimbursement Form Employer: Sign and date this form. www.flexfacts.com. Register. HEADQUARTERS. %���� You will receive a letter indicating the outcome of the investigation, once a decision is reached. FSA General Claim Form Dependent Care Claim Form Direct Deposit Form HIPAA Authorization Form HRA General Claim Form Direct Deposit Form HIPAA Authorization Form HSA How much can I contribute? Failure to return the form may affect your claim. All forms are in PDF format. If your address has changed … Click here to download Adobe PDF Reader. 3 0 obj Please send this form along with all applicable receipts to: 1200 River Ave, Suite SC, Lakewood, NJ 08701 Fax: 877-747-8564 E-Mail: Claims@flexfacts.com Personal Information E-mail. Download forms for the Employer, Employee, Cobra or HSA. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Click on the FSA Eligible Expense Table link at the bottom of the page and enter in Access Code “flex2011”. Sign in Username. Claim Forms. 5050 Quorum Drive, Suite 700, Additional Debit Card Request Form Complete and remit this form if requesting an additional card for your spouse or any dependents. <>/Metadata 220 0 R/ViewerPreferences 221 0 R>> IRS form 2441 should be filed with your tax form 1040 when dependent care has been deducted from your pay. <> Log on now to update personal information, view your policy, request a policy loan, request changes to your benefit amounts and file claims … A Claim Form is a legal document used for submitting a claim. Eligible expenses include day care, baby-sitting, and general purpose … Over-the-counter drugs not prescribed by your doctor do not qualify as an FSA expense. If requesting a replacement card for yourself, spouse or dependents, please contact us at 866-451-3399 or customerservice@discoverybenefits.com and we would be happy to assist you. <> endobj Pdf SHIF Enrollment form BeneCardPBF Enrollment form Fax: 847-699-6906 note: claim! 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