Get Payflex Forms

Filling out the Payflex Forms online can simplify the process of managing health and dependent care claims. This guide provides a step-by-step approach to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your Payflex Forms online.

1. Click 'Get Form' button to access the Payflex Forms and open it in the editor.
2. Begin by entering your employee name and member number in the designated fields. This member number can either be your Social Security Number or your employer-assigned number.
3. Fill in the employer name field under your personal information section. For any address changes, contact your employer’s HR/Benefits department, as they cannot be processed directly here.
4. Proceed to the Health Care Claims section. For claims related to services covered by insurance, ensure to submit the required Explanation of Benefits Statement (EOB) along with a detailed statement from the service provider if necessary.
5. For expenses not covered by insurance, include an itemized statement detailing the provider’s information, patient name, service description, and the amount charged in accordance with the claim requirements.
6. If you are making claims for prescription and over-the-counter medications, ensure that these are supported by a printout from the pharmacy or clearly identifiable on an itemized receipt.
7. For dependent child or adult day care claims, complete the respective sections and ensure to attach an itemized statement from your day care provider if they do not fill out the provider information on the form.
8. In the provider information section, you may have your day care provider sign to validate the expenses claimed.
9. Complete the certification section stating that the expenses are incurred for eligible services and have not been reimbursed through any other source.
10. Finally, sign and date the form to complete the process. Remember to make copies for your records since the original documents will not be returned. You can save changes, download, print, or share the filled form as needed.

Start filling out your Payflex Forms online today to manage your health and dependent care claims effectively.