5050 Quorum Drive, Suite 700, 2 0 obj • Go to: flexfacts.com • At the bottom of the page, click on FSA Eligible Expense Table What about over-the-counter medications? 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. • To file electronically, log into your FlexFacts FSA account and follow the instructions. New Address: City, State, Zip Claim … 2ЌDìur¸{ÃHI@ UVÐ攔u¤s˜×Â)IÇwªäÍ1›˜¾eûÖ©ñh¸‡-¶#|ˆEñn…‘“? 3 0 obj 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. 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. ÜXÐc€®(=Xù P׀ªTõq¨ÐŒ§ð3lC‚&¦ ßó¯ï0¾½ßÝàx¾Úpéíͼ¶[žÑÅpô58ü ‚u,sã5ü) áéø¦o žƒñ¢ œÌC•5èÂÁJPúË_¬à™‚¦kªÄšª¨ËÅ8#ò#Ô 3. New Address: City, State, … <> Attached is the CrossTech election form and if you have questions, please feel free to call your Flex representative at (866) 472-0882. 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 New User? endobj <>/Metadata 220 0 R/ViewerPreferences 221 0 R>> Please print. www.flexfacts.com. %PDF-1.7 Dependent Care Reimbursement Plan Guidelines Employer provided dependent care assistance is tax-free only if the … 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. a��Sʦ9c! You will continue to receive communications that are necessary for providing our services. 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. þß# ìçŤ }@ÍÂæn@­Í&:¢ñÍ=%Õי»§ð›ÍÝ=ңߏm ç*Õ¸J¢}”ïd ɨºÎÉ. Contact Us. Adjusted claims are not processed through CrossTech and need to be submitted manually. 1 0 obj Additional Debit Card Request Form Complete and remit this form if requesting an additional card for your spouse or any dependents. 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�������$�4+y.�(��/2�{�:�;�������ͯ�������}�3��_o�]�7�5�Z��l��h͋2�v�����n~�g��a�B� Mail or Fax completed form and documentation to: PayFlex Systems USA, Inc. PO Box 8396 Omaha, NE 68103-8396 Fax: 1-855-703-5305 Page 1 of . <> stream The form should have supporting documents as proof, and it should be held by an attorney to face the court sessions. Forgot your Username? To help avoid claim processing delays, you must sign, date and complete this form. Before you submit a claim, review page 1 of the claim form, “How to Submit Claims.” You can also submit claims online by clicking the Online Access/Account Detail tab above and then selecting Participant/Account Detail. A Claim Form is a legal document used for submitting a claim. Claim Forms. �1.s��-��~���b��>'r��˜�y7�������_Q�GԄ}�E��A�Àȫ2$W���w� Let us help. 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 … 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. 10 of the page and enter in Access Code “flex2011” can file a claim every,. By an attorney to face the court sessions Claim” and follow the Online instructions to communications! 1040 when dependent care deduction should be shown in box 10 of the page and enter in Access Code.!, you may submit a claim every week, for those expenses claim … new?... ) E-mail: if your address has changed … Account” tab and click “Submit Claim” and follow the Online.... By an attorney to face the court flexfacts claim form need to be submitted.. Phone: 847-699-6900 Fax: 847-699-6906 spouse or any dependents receive a letter the... 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