Adjusted claims are not processed through CrossTech and need to be submitted manually. If requesting a replacement card for yourself, spouse or dependents, please contact us at 866-451-3399 or [email protected] and we would be happy to assist you. Click here to establish your username and password to manage your account. Due to the time it takes to gather all the documents relevant to your claim, it may take up to 90 days to … FIELD OFFICE. • Go to: flexfacts.com • At the bottom of the page, click on FSA Eligible Expense Table What about over-the-counter medications? To protect your personal information, we collect your password on a separate page. Manual claims are reimbursed via direct … Click here to download Adobe PDF Reader. You must also include supporting documentation. Contribution Grid for Spouses Qualifying HSA … Customers (Individuals, Employees & Their Families) We make it easier to access your account information. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> �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. 2 0 obj New User? Deductions are authorized on a yearly basis during the open enrollment period. To be reimbursed for over-the-counter medications, you must submit your claim with a prescription … 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. }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 FlexFacts. Note: Paperless claim submission is only available to PPO participants. Complete all entries on this Enrollment Form. Please send the completed claim form and detailed bills/ EOBs to: Email: [email protected] Fax: 877-747-8564 Mail: 1200 River Avenue, Suite 10E, Lakewood, NJ 08701 Medical & Dependent Care Claim Form Let us help. Dependent Care Reimbursement Plan Guidelines Employer provided dependent care assistance is tax-free only if the … … Please print. endobj a��Sʦ9c! www.flexfacts.com. 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. All forms are in PDF format. 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. Click on the FSA Eligible Expense Table link at the bottom of the page and enter in Access Code “flex2011”. We will maintain the confidentiality of your personal information in accordance with our privacy policy. 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 … Contact Us. Account” tab and click “Submit Claim” and follow the Online instructions. 877-943-2287. 1200 River Ave, Suite 10E Lakewood, NJ 08701 www.FlexFacts.com. Did you know that you can file a claim … • To file electronically, log into your FlexFacts FSA account and follow the instructions. Attached is the CrossTech election form and if you have questions, please feel free to call your Flex representative at (866) 472-0882. Sign in Username. Click here to download Adobe PDF Reader. 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 … Cellphones have become just as vital to business as a land line, which makes cellphone use a legitimate, deductible business expense. The form should have supporting documents as proof, and it should be held by an attorney to face the court sessions. endobj Eligible expenses include day care, baby-sitting, and general purpose … �1.s��-��~���b��>'r��˜�y7�������_Q�GԄ}�E��A�Àȫ2$W���w� Employee Name (last name, first name) Social … If your address has changed … þß# ìçŤ }@ÍÂæ[email protected]­Í&:¢ñÍ=%Õי»§ð›ÍÝ=ңߏm ç*Õ¸J¢}”ïd ɨºÎÉ. <>/Metadata 220 0 R/ViewerPreferences 221 0 R>> Email: Email your completed Claim Form and receipts to [email protected] 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 … 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, 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. 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. Don’t have an account? FLEX BENEFIT ADMINISTRATORS www.fbaflex.com [email protected] PO BOX 800518 HOUSTON, TX 77280-0518 PHONE (713) 460-FLEX (3539) FAX (713) 460-3550 Claim for Reimbursement Form Employer: However, you may submit a claim every week, at the end of that week, for those expenses. 8700 W. Bryn Mawr Avenue, Suite 1010S, Chicago, IL 60631 Phone: 847-699-6900 Fax: 847-699-6906. Failure to return the form may affect your claim. Employer: Last Four Digits of Your Social Security Number Phone: ( ) E-mail: If your address has changed please list the new address below. 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. Sign in. 4 0 obj Or, you can snap a picture of your documentation and submit via the ASIFlex mobile … Personal Information . 3 0 obj Flex Facts, 1200 River Ave, Suite 5C, Lakewood, NJ 08701, www.flexfacts.com, 877-94-FACTS (32287) Spending Account Claim Form Personal Information 1 0 obj Fillable PDF SHIF Enrollment Form BeneCardPBF Enrollment Form Opt-out 2ЌDìur¸{Ã[email protected] UVÐ攔u¤s˜×Â)IÇwªäÍ1›˜¾eûÖ©ñh¸‡-¶#|ˆEñn…‘“? ©ConnectYourCare Form 400001 (10/2014) Flexible Spending Account Enrollment Form . %PDF-1.7 Forgot your Username? 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. You will continue to receive communications that are necessary for providing our services. 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? A Claim Form is a legal document used for submitting a claim. Tired of looking for receipts, claim forms … 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 . 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 <> All forms are in PDF format. The Dependent Care deduction should be shown in box 10 of the W2 form from your employer. Last Employer. HEADQUARTERS. ... • 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, [email protected] Upon receipt of the form, an investigator will review the documents. Spending Account Claim Form Full Name. Last Four Digits of Your Social Security Number Phone. WAIT! 5050 Quorum Drive, Suite 700, ÜXÐc€®(=Xù P׀ªTõq¨ÐŒ§ð3lC‚&¦ ßó¯ï0¾½ßÝàx¾Úpéíͼ¶[žÑÅpô58ü ‚u,sã5ü) 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� ��1!cE�P��rJ�L�iG!���SbQ� • To file electronically, log into your FlexFacts FSA account and follow the instructions. To help avoid claim processing delays, you must sign, date and complete this form. 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? New Address: City, State, … Claim Forms. <> Sign and date this form. Additional Debit Card Request Form Complete and remit this form if requesting an additional card for your spouse or any dependents. B�lV�aO�L���?�̖Op���ω�0�V��h�nJ �s�W��*[email protected]_�Y_V�r�v9!.���%�"�C#;�ja�f_��?O�y�� 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 endobj %���� An HRA is a reimbursement account set up and funded by your employer to cover eligible healthcare expenses. Find the most frequently used carrier forms you need right here - just click and print! Follow these easy steps: 1. You will receive a letter indicating the outcome of the investigation, once a decision is reached. • 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 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. stream 2. Download forms for the Employer, Employee, Cobra or HSA. 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. Submit it to your Human Resources Department. New Address: City, State, Zip Claim … Employer: Social Security Number Phone: ( ) E-mail: If your address has changed please list the new address below. 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