However, you may submit a claim every week, at the end of that week, for those expenses. Additional Debit Card Request Form Complete and remit this form if requesting an additional card for your spouse or any dependents. 3. Sign in Username. The Dependent Care deduction should be shown in box 10 of the W2 form from your employer. info@flexfacts.com. 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. 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. Let us help. Claim Forms. To do so, click âManageâ or âOpt-outâ on one of the marketing emails you received or click the Opt-out link below and complete the form request. Attached is the CrossTech election form and if you have questions, please feel free to call your Flex representative at (866) 472-0882. %PDF-1.7 Sign in. endobj You will continue to receive communications that are necessary for providing our services. 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. stream New User? 3 0 obj Sign and date this form. Last Four Digits of Your Social Security Number Phone. <> WAIT! Forgot your Username? Before you submit a claim, review page 1 of the claim form, âHow to Submit Claims.â You can also submit claims online by clicking the Online Access/Account Detail tab above and then selecting Participant/Account Detail. 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? Or, you can snap a picture of your documentation and submit via the ASIFlex mobile ⦠IRS form 2441 should be filed with your tax form 1040 when dependent care has been deducted from your pay. Personal Information . ©ConnectYourCare Form 400001 (10/2014) Flexible Spending Account Enrollment Form . <> }8[©² ÿuVRQìR&Ò= GHU2GqLõ?ôÅ É1õb£ôduUÖÒÁ"¡AS¢CD£²ürª\6¥h»°¡%£)Më¦$£ò*dbS\@apbÀñ¦ô\3%itgEã Æ5)à 0®ú(ãäÓùPé 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 2. Register. endobj Due to the time it takes to gather all the documents relevant to your claim, it may take up to 90 days to ⦠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 ⦠��1!cE�P��rJ�L�iG!���SbQ� A Claim Form is a legal document used for submitting a claim. Deductions are authorized on a yearly basis during the open enrollment period. Contact Us. Opt-out Flex Facts, 1200 River Ave, Suite 5C, Lakewood, NJ 08701, www.flexfacts.com, 877-94-FACTS (32287) Spending Account Claim Form Personal Information Follow these easy steps: 1. New Address: City, State, ⦠You must also include supporting documentation. Info@FlexFacts.com FSA Spending Account Claim Form ⦠⢠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. 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. Download forms for the Employer, Employee, Cobra or HSA. www.flexfacts.com. You will receive a letter indicating the outcome of the investigation, once a decision is reached. Complete all entries on this Enrollment Form. Employer: Social Security Number Phone: ( ) E-mail: If your address has changed please list the new address below. Contribution Grid for Spouses Qualifying HSA ⦠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 HEADQUARTERS. To be reimbursed for over-the-counter medications, you must submit your claim with a prescription ⦠Customers (Individuals, Employees & Their Families) We make it easier to access your account information. Cellphones have become just as vital to business as a land line, which makes cellphone use a legitimate, deductible business expense. Click on the FSA Eligible Expense Table link at the bottom of the page and enter in Access Code âflex2011â. Click here to establish your username and password to manage your account. Over-the-counter drugs not prescribed by your doctor do not qualify as an FSA expense. 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. To help avoid claim processing delays, you must sign, date and complete this form. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> ⢠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. a��Sʦ9c! 2ÐDìur¸{ÃHI@ UVÐæu¤s×Â)IÇwªäÍ1¾eûÖ©ñh¸-¶#|Eñn ? Eligible expenses include day care, baby-sitting, and general purpose ⦠Accountâ tab and click âSubmit Claimâ and follow the Online instructions. %���� But for most of us, cellphones are also inextricably linked to our personal lives, so itâs a deduction that the IRS scrutinizes very carefully to make sure personal electronics use isnât being ⦠�1.s��-��~���b��>'r���y7�������_Q�GԄ}�E��A�Àȫ2$W���w� Before you can access your account, you must register with the site and create a username and password.Test To protect your personal information, we collect your password on a separate page. 5050 Quorum Drive, Suite 700, Submit it to your Human Resources Department. Spending Account Claim Form Full Name. áéø¦o ñ¢ ÌC5èÂÁJPúË_¬à¦kªÄª¨ËÅ8#ò#Ô Please print. We will maintain the confidentiality of your personal information in accordance with our privacy policy. Donât have an account? ⦠... ⢠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, An HRA is a reimbursement account set up and funded by your employer to cover eligible healthcare expenses. endobj Fillable PDF SHIF Enrollment Form BeneCardPBF Enrollment Form 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 . You can also opt out of marketing communications. Dependent Care Reimbursement Plan Guidelines Employer provided dependent care assistance is tax-free only if the ⦠Manual claims are reimbursed via direct ⦠þß# ìçŤ }@ÍÂæn@Í&:¢ñÍ=%Õ×»§ðÍÝ=Ò£ßm ç*Õ¸J¢}ïd ɨºÎÉ. Note: Paperless claim submission is only available to PPO participants. �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. 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. Click here to download Adobe PDF Reader. <>/Metadata 220 0 R/ViewerPreferences 221 0 R>> Adjusted claims are not processed through CrossTech and need to be submitted manually. Last Employer. 2 0 obj ÜXÐc®(=Xù PתTõq¨Ð§ð3lC&¦ ßó¯ï0¾½ßÝàx¾Úpéíͼ¶[ÑÅpô58ü u,sã5ü) 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. The form should have supporting documents as proof, and it should be held by an attorney to face the court sessions. If your address has changed ⦠877-943-2287. Employee Name (last name, first name) Social ⦠Failure to return the form may affect your claim. Click here to download Adobe PDF Reader. 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: All forms are in PDF format. Tired of looking for receipts, claim forms ⦠1200 River Ave, Suite 10E Lakewood, NJ 08701 www.FlexFacts.com. Log on now to update personal information, view your policy, request a policy loan, request changes to your benefit amounts and file claims ⦠B�lV�aO�L���?�̖Op���ω�0�V��h�nJ �s�W��*s!C@_�Y_V�r�v9!.���%�"�C#;�ja�f_��?O�y�� 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� 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. 8700 W. Bryn Mawr Avenue, Suite 1010S, Chicago, IL 60631 Phone: 847-699-6900 Fax: 847-699-6906. 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? FlexFacts. 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 1 0 obj Employer: Last Four Digits of Your Social Security Number Phone: ( ) E-mail: If your address has changed please list the new address below. ⢠Go to: flexfacts.com ⢠At the bottom of the page, click on FSA Eligible Expense Table What about over-the-counter medications? Find the most frequently used carrier forms you need right here - just click and print! 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. ⢠To file electronically, log into your FlexFacts FSA account and follow the instructions. ⢠To file electronically, log into your FlexFacts FSA account and follow the instructions. 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