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  • Flores Reimbursement Form

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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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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.

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.

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.

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!

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.

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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© 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
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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