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  • Flores Reimbursement Form

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PLEASE DO NOT USE STAPLES FSADirect DEPENDENT CARE REIMBURSEMENT PLEASE PRINT CLEARLY. USE ALL CAPITAL LETTERS. GENERAL INFORMATION Group Plan ID SAS Institute Inc. Partic. ID 100747691 If this is a new address check here First Last Name Address City Phone State - Zip E-Mail Important You must attach receipts from your dependent care provider or have your provider sign in the appropriate block next to the detail item. Do not attach checks or cred.

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You may scan your claim and upload it to our secure website or complete your claim detail online at .flores247.com. FLORES MOBILE SMARTPHONE APP: Use your phone's camera to take a picture of your documentation and upload. Download Flores Mobile through Apple Store or Google Play.

In the event you aren't able to utilize your Flores Benefits Card, you can always submit a claim for reimbursement. To file a claim, please complete a claim form and include supporting documentation, such as an itemized receipt, showing the date of service, cost, and a brief description of the service.

Once you have paid for expenses that qualify for reimbursement from the FSA, you will need to complete a claim form provided by your employer and attach receipts or proof of payment with the form. The receipts must include specific information to prove that the payment was for qualified expenses.

Your HSA is similar to a checking account. You are responsible for ensuring money is spent on qualified purchases only and maintaining records. Payments can be made via check, online bill-pay, your Flores Benefit Card, or you can reimburse yourself if you pay out-of-pocket for an expense.

Flores247 Employer Web Portal for access to robust reports, enrollment tools, and more for all plans administered by Flores.

Submit Your Claim in One of These Ways Log in to your account. ... Once you have logged into your account, click Submit Receipt or Claim and select your Reimbursement Option. Follow the step-by-step instructions. Upload digital copies of your itemized receipts (and other documentation if needed).

You can use your Flores Benefits Card to pay for expenses incurred during your active enrollment period in the current plan year. If a provider or merchant does not accept cards, you do have the option to file a manual request for reimbursement of your eligible out-of-pocket cost.

Your employer offers the Flores Benefits Card to employees who enroll in an eligible benefit plan. The card will allow you to pay for eligible expenses at participating providers at the time services are rendered, thus eliminating or reducing your out-of-pocket cost at the time of the purchase or service.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232