FSADirect REQUEST FOR MEDICAL REIMBURSEMENT PLEASE PRINT CLEARLY. USE ALL CAPITAL LETTERS. PLEASE DO NOT USE STAPLES ACCOUNT HOLDER GENERAL INFORMATION Plan ID: 1000747691 Group: SAS Institute Inc.
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How to fill out the Flores Reimbursement Form online
Completing the Flores Reimbursement Form online can streamline your reimbursement process. This guide provides clear instructions to help you navigate each section of the form with ease.
Follow the steps to successfully complete your reimbursement form.
- Press the ‘Get Form’ button to access the Flores Reimbursement Form and open it in your preferred online editor.
- Begin by entering the account holder's general information. This includes the Plan ID, Group, and Participant ID number, ensuring clarity and accuracy.
- Fill in your personal details in the designated fields: first name, last name, address, city, state, zip code, phone number, and email. Make sure to use capital letters for readability.
- In the 'Reimbursement Request Detail' section, complete one section for each receipt you are submitting. Indicate the date of service, service code, amount requested for reimbursement, patient name, and name of the provider.
- Use the service code key provided to select the appropriate code for each service rendered. Codes include medical, dental, vision, and others as specified.
- After filling out the details for each service, sum the total requested for reimbursement at the bottom of the page.
- In the 'Reimbursement Authorization' section, review the certification statement carefully. Sign and date the form to confirm that the expenses are valid and have not been claimed elsewhere.
- Once you have completed all sections of the form, save your changes, and download or print the completed form for submission.
- Submit your claim by faxing it to the provided numbers or mailing it to the specified address. Ensure all supporting documents, like itemized bills, are attached.
Complete your Flores Reimbursement Form online today to experience a smooth reimbursement process.
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What can I use my Flores card for?
You can use your Flores Debit Card to pay for expenses incurred during your active enrollment period in the current plan year. If a provider or merchant does not accept Debit Cards, you do have the option to file a manual request for reimbursement of your eligible out-of-pocket cost.
How do I get a reimbursement from Flores?
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.
What is a Flores PID number?
Send PID Request. Your Participant ID is a unique ID number that was assigned to you when you initially enrolled in your account with Flores. This was sent to you by mail, or email, if an email address was provided at the time of your enrollment.
How does Flores HSA work?
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.
How does Flores FSA work?
You can submit your claim for the full amount of eligible expenses you'll incur during the plan year. We'll enter this as a pending claim to your account and as you contribute to the account through your pre-tax payroll deductions, we will automatically reimburse you the same day we receive the contribution!
What is Flores247?
Flores247 Employer Web Portal for access to robust reports, enrollment tools, and more for all plans administered by Flores.
What is the Flores Benefits Card used for?
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.
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